Provider Demographics
NPI:1780774109
Name:FREE, BRADLEY R (DC)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:R
Last Name:FREE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 LOCUST STREET
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081
Mailing Address - Country:US
Mailing Address - Phone:815-625-3733
Mailing Address - Fax:815-625-3732
Practice Address - Street 1:2202 LOCUST STREET
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081
Practice Address - Country:US
Practice Address - Phone:815-625-3733
Practice Address - Fax:815-625-3733
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008318111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
020649979OtherTAX ID
IL09832009OtherBLUE CROSS BLUE SHIELD
U93612Medicare UPIN
020649979 U93612Medicare UPIN
IL09832009OtherBLUE CROSS BLUE SHIELD