Provider Demographics
NPI:1184744765
Name:FREIDEL, BRADLEY ROBERT (DO)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:ROBERT
Last Name:FREIDEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 N RUTHERFORD ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MO
Mailing Address - Zip Code:63552-2020
Mailing Address - Country:US
Mailing Address - Phone:660-385-8900
Mailing Address - Fax:660-385-8708
Practice Address - Street 1:1201 N RUTHERFORD ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-2020
Practice Address - Country:US
Practice Address - Phone:660-385-8900
Practice Address - Fax:660-385-8708
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE324207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE07035OtherBLUE CROSS PROVIDER #
NE20065242968066OtherTRICARE PROVIDER
NE235966OtherMIDLANDS CHOICE
NE200652429OtherUNITED HEALTHCARE
MTP00128031OtherRAILROAD MEDICARE
NE200652429Medicaid
NE235966OtherMIDLANDS CHOICE
MTP00128031OtherRAILROAD MEDICARE