Provider Demographics
NPI:1760476519
Name:BITTLE, BRADLEY KEITH (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:KEITH
Last Name:BITTLE
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:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:24 S MOUNT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4914
Practice Address - Country:US
Practice Address - Phone:573-331-5544
Practice Address - Fax:573-331-5545
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006023028207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200387790Medicaid
IL1760476519Medicaid
KY7100095140Medicaid
AR165391001Medicaid
MO536594OtherANTHEM BCBS
MO206881716Medicaid
MOP00382733OtherRR MCR
MO248625OtherHEALTHLINK
AR165391001Medicaid
MO963833247Medicare PIN