Provider Demographics
NPI:1659466449
Name:PHILLIPS, BRADLEY J (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7261 MERCY RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2311
Mailing Address - Country:US
Mailing Address - Phone:402-398-6248
Mailing Address - Fax:402-829-8513
Practice Address - Street 1:601 N 30TH ST
Practice Address - Street 2:SUITE 2803
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2128
Practice Address - Country:US
Practice Address - Phone:402-717-4909
Practice Address - Fax:402-717-6062
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080920208600000X, 2086S0102X
NE286132086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH34876Medicare UPIN