Provider Demographics
NPI:1710950423
Name:BRADSTREET, RICHARD PERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:PERRY
Last Name:BRADSTREET
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:570-887-4193
Is Sole Proprietor?:No
Enumeration Date:2006-02-12
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191061-1207ZP0102X
PAMD043186L207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA220029205OtherRR MEDICARE PIN
PACC9269OtherRR MEDICARE GROUP
PA0012731650001Medicaid
PAGU039827OtherMEDICARE GROUP
NY01297263Medicaid
PA220029205OtherRR MEDICARE PIN
PAGU039827OtherMEDICARE GROUP