Provider Demographics
NPI:1770046997
Name:TAIT, BRADLEY ALAN (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALAN
Last Name:TAIT
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:USA MEDDAC
Mailing Address - Street 2:11050 MOUNT BELVEDERE BLVD
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-0000
Mailing Address - Country:US
Mailing Address - Phone:315-772-2778
Mailing Address - Fax:
Practice Address - Street 1:USA MEDDAC
Practice Address - Street 2:11050 MOUNT BELVEDERE BLVD
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-0000
Practice Address - Country:US
Practice Address - Phone:315-772-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-14
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY317171207P00000X
GA10772207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty