1588691638 NPI number — DR. BRADLEY JOSEPH KOMROWSKI-POPPEN PHD

Table of content: DR. BRADLEY JOSEPH KOMROWSKI-POPPEN PHD (NPI 1588691638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588691638 NPI number — DR. BRADLEY JOSEPH KOMROWSKI-POPPEN PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOMROWSKI-POPPEN
Provider First Name:
BRADLEY
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POPPEN
Provider Other First Name:
BRADLEY
Provider Other Middle Name:
JK
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1588691638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2817 REILLY ROAD
Provider Second Line Business Mailing Address:
MCXC-COD CREDENTIALS WOMACK ARMY MEDICAL CENTER
Provider Business Mailing Address City Name:
FORT BRAGG
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-907-8922
Provider Business Mailing Address Fax Number:
910-907-6069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2817 REILLY ROAD DOBH
Provider Second Line Business Practice Location Address:
WOMACK AMC
Provider Business Practice Location Address City Name:
FT BRAGG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-907-6825
Provider Business Practice Location Address Fax Number:
910-907-8521
Provider Enumeration Date:
06/26/2006

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: 103T00000X , with the licence number:  985 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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