1760476519 NPI number — BRADLEY KEITH BITTLE MD

Table of content: CHELSEA M SNYDER NCC, LPC (NPI 1568934156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760476519 NPI number — BRADLEY KEITH BITTLE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BITTLE
Provider First Name:
BRADLEY
Provider Middle Name:
KEITH
Provider Name Prefix Text:
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:
1760476519
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 801143
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64180-1143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-331-5583
Provider Business Mailing Address Fax Number:
573-331-5079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24 S MOUNT AUBURN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE GIRARDEAU
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63703-4914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-331-5544
Provider Business Practice Location Address Fax Number:
573-331-5545
Provider Enumeration Date:
09/08/2005

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: 207RS0012X , with the licence number:  2006023028 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 2006023028 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200387790 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1760476519 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100095140 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 165391001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 536594 . This is a "ANTHEM BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 206881716 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00382733 . This is a "RR MCR" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 248625 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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