Provider Demographics
NPI:1336407147
Name:BRADLAKE MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:BRADLAKE MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHINWE
Authorized Official - Middle Name:C
Authorized Official - Last Name:UMEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-232-7162
Mailing Address - Street 1:P.O BOX 148576
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37214
Mailing Address - Country:US
Mailing Address - Phone:615-232-7162
Mailing Address - Fax:615-232-7308
Practice Address - Street 1:500 MAPLELEAF DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37210
Practice Address - Country:US
Practice Address - Phone:615-232-7162
Practice Address - Fax:615-232-7308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 208VP0000X
TNMD0000014656207R00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1528386Medicaid
TNF04939Medicare UPIN