Provider Demographics
NPI:1881663367
Name:HUBBARD, BRADLEY L (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:L
Last Name:HUBBARD
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 1:24 FRANK LLOYD WRIGHT DR
Mailing Address - Street 2:PO BOX 0446 - LOBBY J
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:5325 ELLIOTT DRIVE
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-712-8000
Practice Address - Fax:734-712-4429
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059044174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3033426Medicaid
MI0M32570Medicare PIN
MIOH16128031Medicare PIN
MI0M32340Medicare PIN
MIE30257Medicare UPIN
MI3033426Medicaid