Provider Demographics
NPI:1023312915
Name:BRENT, BRADLEY
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:BRENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 DEAUVILLE DR
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146-2902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 DEAUVILLE DR
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-2902
Practice Address - Country:US
Practice Address - Phone:412-373-3933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041032E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics