Provider Demographics
NPI:1760642607
Name:T BRADLEY BENEDICT MD PA
Entity Type:Organization
Organization Name:T BRADLEY BENEDICT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:BENEDICT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-277-2202
Mailing Address - Street 1:901 MEDICAL CENTRE DR STE C
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-4700
Mailing Address - Country:US
Mailing Address - Phone:817-277-2202
Mailing Address - Fax:817-548-9709
Practice Address - Street 1:901 MEDICAL CENTRE DR STE C
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4700
Practice Address - Country:US
Practice Address - Phone:817-277-2202
Practice Address - Fax:817-548-9709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0809174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033845101Medicaid
TXB21194Medicare UPIN
TX033845101Medicaid