Provider Demographics
NPI:1851364111
Name:LANE BRADLEY, MARIELLEN M
Entity Type:Individual
Prefix:MR
First Name:MARIELLEN
Middle Name:M
Last Name:LANE BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 W 96TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6613
Mailing Address - Country:US
Mailing Address - Phone:212-749-3172
Mailing Address - Fax:
Practice Address - Street 1:3959 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1559
Practice Address - Country:US
Practice Address - Phone:212-304-7250
Practice Address - Fax:212-544-1974
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178354208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01370805Medicaid
NYO4L141Medicare ID - Type Unspecified
NC01370805Medicaid