Provider Demographics
NPI:1952349813
Name:BRADLEY, PAUL S (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:S
Last Name:BRADLEY
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 1:210 EAST DERENNE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-644-5300
Mailing Address - Fax:912-644-5260
Practice Address - Street 1:340 EISENHOWER DRIVE
Practice Address - Street 2:SUITE 1200
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406
Practice Address - Country:US
Practice Address - Phone:912-443-4200
Practice Address - Fax:912-355-8124
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030016207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00630127OtherRR MEDICARE
GA000353064KMedicaid
GA01259169OtherAMERIGROUP
SCG30016Medicaid
SCG30016Medicaid
GA511I110484Medicare PIN