1558465922 NPI number — SYBIL A BRADLEY-DALLAS NP

Table of content: SYBIL A BRADLEY-DALLAS NP (NPI 1558465922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558465922 NPI number — SYBIL A BRADLEY-DALLAS NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY-DALLAS
Provider First Name:
SYBIL
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1558465922
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:
2207 PETERS CREEK ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24017-1618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
540-562-1567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2138 LANGHORNE SQUARE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNCHBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-845-3178
Provider Business Practice Location Address Fax Number:
434-846-8346
Provider Enumeration Date:
09/07/2006

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: 363LX0001X , with the licence number:  0024082899 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010014786 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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