Provider Demographics
NPI:1851521744
Name:BRADLEY, MACON SAMUEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MACON
Middle Name:SAMUEL
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1610
Mailing Address - Street 2:DOWELL RD
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642
Mailing Address - Country:US
Mailing Address - Phone:270-866-4141
Mailing Address - Fax:
Practice Address - Street 1:153 DOWELL RD
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642-4579
Practice Address - Country:US
Practice Address - Phone:270-866-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-25
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03294207Q00000X, 207QA0401X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine