Provider Demographics
NPI:1821265349
Name:BRADLEY J PHILLIPS MD LLC
Entity Type:Organization
Organization Name:BRADLEY J PHILLIPS MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ADMINSTRATOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-249-6101
Mailing Address - Street 1:PO BOX 7063
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-7063
Mailing Address - Country:US
Mailing Address - Phone:732-249-6101
Mailing Address - Fax:732-249-6102
Practice Address - Street 1:1543 ROUTE 27
Practice Address - Street 2:SUITE 23
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873
Practice Address - Country:US
Practice Address - Phone:732-249-6101
Practice Address - Fax:732-249-6102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06584600207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7384009Medicaid
NJ7384009Medicaid