Provider Demographics
NPI:1770767253
Name:BRAD E MCCOLLOM DO PA
Entity type:Organization
Organization Name:BRAD E MCCOLLOM DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCCOLLOM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:772-581-8075
Mailing Address - Street 1:787 37TH ST
Mailing Address - Street 2:SUITE E220
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7305
Mailing Address - Country:US
Mailing Address - Phone:772-581-8075
Mailing Address - Fax:772-581-8097
Practice Address - Street 1:7764 BAY STREET
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958
Practice Address - Country:US
Practice Address - Phone:772-581-8075
Practice Address - Fax:772-581-8097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9270207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6779OtherMEDICARE GROUP