Provider Demographics
NPI:1770067589
Name:BRADLEY BIBB MD PLLC
Entity type:Organization
Organization Name:BRADLEY BIBB MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:YORK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-718-2570
Mailing Address - Street 1:4196 HIGHWAY 62 412 STE A
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542-8002
Mailing Address - Country:US
Mailing Address - Phone:708-561-2028
Mailing Address - Fax:501-441-3911
Practice Address - Street 1:49 HIGHWAY 62 412
Practice Address - Street 2:
Practice Address - City:ASH FLAT
Practice Address - State:AR
Practice Address - Zip Code:72513-9594
Practice Address - Country:US
Practice Address - Phone:870-994-7301
Practice Address - Fax:870-994-7488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-18
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty