1508950296 NPI number — DR. STEPHEN K BRADLEY MD

Table of content: DR. STEPHEN K BRADLEY MD (NPI 1508950296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508950296 NPI number — DR. STEPHEN K BRADLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY
Provider First Name:
STEPHEN
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1508950296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1795 S DEVONSHIRE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84108-2562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-860-5905
Provider Business Mailing Address Fax Number:
855-242-1691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1795 S DEVONSHIRE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84108-2562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-860-5905
Provider Business Practice Location Address Fax Number:
855-242-1691
Provider Enumeration Date:
10/03/2006

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: 207L00000X , with the licence number:  172488-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PRA07396 . This is a "MOLINA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: QM0000075886 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 002086464 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17839 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 103500200 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1502954 . This is a "UMWA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 44140 . This is a "HEALTHY U" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 820771 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107006512102 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 73544 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 806727300 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2090168 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870545614SB3 . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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