Provider Demographics
NPI:1669478657
Name:BRADWAY, MARCELLA W (MD)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:W
Last Name:BRADWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-1442
Mailing Address - Country:US
Mailing Address - Phone:413-447-2745
Mailing Address - Fax:413-346-6703
Practice Address - Street 1:777 NORTH ST
Practice Address - Street 2:SUITE 605
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4147
Practice Address - Country:US
Practice Address - Phone:413-447-2745
Practice Address - Fax:413-346-6703
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037814208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001378141Medicaid
CT13206Medicare UPIN
CT001378141Medicaid