1578508529 NPI number — DR. LYNN E BRADFORD PHD, HSPP

Table of content: DR. LYNN E BRADFORD PHD, HSPP (NPI 1578508529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578508529 NPI number — DR. LYNN E BRADFORD PHD, HSPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADFORD
Provider First Name:
LYNN
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD, HSPP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578508529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N SHADELAND AVE
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46219-4959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-962-4836
Provider Business Mailing Address Fax Number:
317-962-8646

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 KESSLER BOULEVARD EAST DR
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46220-2890
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-475-6200
Provider Business Practice Location Address Fax Number:
317-475-6212
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  20040774 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 111672000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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