Provider Demographics
NPI:1710991500
Name:MAGILL, BRADLEY J (DPM)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:MAGILL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135B MIDWAY DR
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-3857
Mailing Address - Country:US
Mailing Address - Phone:814-371-2348
Mailing Address - Fax:814-372-6090
Practice Address - Street 1:135B MIDWAY DR
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801
Practice Address - Country:US
Practice Address - Phone:814-371-2348
Practice Address - Fax:814-372-6090
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003260L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA201856OtherUPMC
PA000000090188OtherUNISON THREE RIVERS MEDPL
PA0011362640005Medicaid
PA364643OtherHIGHMARK BC BS PA
PA1035572OtherGATEWAY PA MEDICAID
PA580437Medicare PIN
PA201856OtherUPMC
PA1035572OtherGATEWAY PA MEDICAID