Provider Demographics
NPI:1245272525
Name:BRADFORD FAMILY MEDICINE, INC.
Entity type:Organization
Organization Name:BRADFORD FAMILY MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:M
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-362-6962
Mailing Address - Street 1:14 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-3335
Mailing Address - Country:US
Mailing Address - Phone:814-362-6962
Mailing Address - Fax:814-362-4956
Practice Address - Street 1:14 N 3RD ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-3335
Practice Address - Country:US
Practice Address - Phone:814-362-6962
Practice Address - Fax:814-362-4956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-068703-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH14841Medicare UPIN
PA075324Medicare ID - Type Unspecified