Provider Demographics
NPI:1699029603
Name:BRAD HEADLEY MD FACS LLC
Entity Type:Organization
Organization Name:BRAD HEADLEY MD FACS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL SURGERY
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:HEADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-237-3291
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-0568
Mailing Address - Country:US
Mailing Address - Phone:478-237-3291
Mailing Address - Fax:478-237-4344
Practice Address - Street 1:120 VICTORY DR # A
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-3235
Practice Address - Country:US
Practice Address - Phone:478-237-3291
Practice Address - Fax:478-237-4344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039125208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA338041OtherWELLCARE
GA000618241AMedicaid
GA10045911OtherAMERIGROUP
GA52495099OtherBCBS
GA000618241AMedicaid
GA02BDCLDMedicare PIN