Provider Demographics
NPI:1689603094
Name:BRADLEY, ROBERT GRAYDON (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GRAYDON
Last Name:BRADLEY
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 1:1270 SOLUTIONS CTR
Mailing Address - Street 2:P.O. BOX 771270
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1002
Mailing Address - Country:US
Mailing Address - Phone:513-542-6898
Mailing Address - Fax:513-542-7972
Practice Address - Street 1:7502 STATE ROAD
Practice Address - Street 2:SUITE 1180
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-2800
Practice Address - Country:US
Practice Address - Phone:513-232-8181
Practice Address - Fax:513-624-2956
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077683174400000X
OH35-077683208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH311527667050OtherCARESOURCE
OH01417721OtherAMERIGROUP
OH743911OtherBUCKEYE
OHP00931021OtherRAILROAD MEDICARE
OH2402939Medicaid
OH$$$$$$$$$00OtherWORKERS COMP
OH743911OtherBUCKEYE
OHH84617Medicare UPIN