Provider Demographics
NPI:1700893013
Name:ALLEN, BRADLEY R (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:R
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055
Mailing Address - Country:US
Mailing Address - Phone:220-564-4151
Mailing Address - Fax:220-564-7153
Practice Address - Street 1:1320 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEWAR
Practice Address - State:OH
Practice Address - Zip Code:43055
Practice Address - Country:US
Practice Address - Phone:220-564-4151
Practice Address - Fax:220-564-7153
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074360207P00000X
OH35074360A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2065527Medicaid
0853001Medicare PIN
0853002Medicare PIN
G87710Medicare UPIN