Provider Demographics
NPI:1972689586
Name:NICHOLAS BRADLEE DPM
Entity Type:Organization
Organization Name:NICHOLAS BRADLEE DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:586-751-3533
Mailing Address - Street 1:PO BOX 1227
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48090-1227
Mailing Address - Country:US
Mailing Address - Phone:586-751-3533
Mailing Address - Fax:586-751-1817
Practice Address - Street 1:28565 RYAN ROAD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092
Practice Address - Country:US
Practice Address - Phone:586-751-3533
Practice Address - Fax:586-751-1817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MINB000558213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8505050OtherBLUE CROSS BLUE SHIELD
MI5635277OtherBLUE CROSS BLUE SHIELD
MI8505050OtherBLUE CROSS BLUE SHIELD
OP19590Medicare ID - Type Unspecified