1497860464 NPI number — NICHOLAS BRADLEE DPM PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497860464 NPI number — NICHOLAS BRADLEE DPM PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NICHOLAS BRADLEE DPM PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1497860464
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1029
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48099-1029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-244-9565
Provider Business Mailing Address Fax Number:
248-244-8183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1909 LIVERNOIS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-244-9565
Provider Business Practice Location Address Fax Number:
248-244-8183
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRADLEE
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-244-9565

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  NB000558 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5635277 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5635277 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8505050 . This is a "BLUE SHIELD OF MICH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8505050 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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