Provider Demographics
NPI:1639175276
Name:PAGE, BRADFORD R (MS, PT)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:R
Last Name:PAGE
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1188 W UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3009
Mailing Address - Country:US
Mailing Address - Phone:208-336-8250
Mailing Address - Fax:208-345-9514
Practice Address - Street 1:1188 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-336-8250
Practice Address - Fax:208-345-9514
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT6642251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1639175276Medicaid
IDT1047OtherBLUE CROSS OF ID #
ID1653090Medicare ID - Type UnspecifiedMEDICARE PROVIDER #