Provider Demographics
NPI:1679689301
Name:SUMRALL, BRADLEY T (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:T
Last Name:SUMRALL
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 1:800 1ST ST STE 410
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-8306
Mailing Address - Country:US
Mailing Address - Phone:478-743-7068
Mailing Address - Fax:478-741-1354
Practice Address - Street 1:800 1ST ST STE 410
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-8306
Practice Address - Country:US
Practice Address - Phone:478-743-7068
Practice Address - Fax:478-741-1354
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069720174400000X
GA69720207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003133948AMedicaid
GA003133948BMedicaid
GA003133948AMedicaid
SC246834Medicaid