Provider Demographics
NPI:1659543676
Name:ALAN B BRADLEY MD LLC
Entity Type:Organization
Organization Name:ALAN B BRADLEY MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-224-2632
Mailing Address - Street 1:1220 E ELM ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2850
Mailing Address - Country:US
Mailing Address - Phone:419-224-2632
Mailing Address - Fax:419-222-2731
Practice Address - Street 1:1220 E ELM ST
Practice Address - Street 2:SUITE 204
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2850
Practice Address - Country:US
Practice Address - Phone:419-224-2632
Practice Address - Fax:419-222-2731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042423B207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0492864Medicaid
OH0492864Medicaid
OHBR4139431Medicare PIN