Provider Demographics
NPI:1265767859
Name:HAL BRADFORD MD PA
Entity type:Organization
Organization Name:HAL BRADFORD MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:HAL
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-444-1440
Mailing Address - Street 1:3000 N MARKET AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3507
Mailing Address - Country:US
Mailing Address - Phone:479-444-1440
Mailing Address - Fax:479-444-1447
Practice Address - Street 1:3000 N MARKET AVE.
Practice Address - Street 2:SUITE E
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3507
Practice Address - Country:US
Practice Address - Phone:479-444-1440
Practice Address - Fax:479-444-1447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-15
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-7898174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR124896001Medicaid
AR124896001Medicaid