Provider Demographics
NPI:1295780872
Name:HAMMERSLEY, BRADLEY R
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:R
Last Name:HAMMERSLEY
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 1:632 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-1747
Mailing Address - Country:US
Mailing Address - Phone:765-473-4220
Mailing Address - Fax:765-473-4223
Practice Address - Street 1:632 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1747
Practice Address - Country:US
Practice Address - Phone:765-473-4220
Practice Address - Fax:765-473-4223
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000906213E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2009854730Medicaid
IN267640Medicare PIN
IN6249610001Medicare NSC