1689669301 NPI number — DOUGLAS L BRADLEY MD

Table of content: DOUGLAS L BRADLEY MD (NPI 1689669301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689669301 NPI number — DOUGLAS L BRADLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY
Provider First Name:
DOUGLAS
Provider Middle Name:
L
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:
1689669301
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17067 S OUTER RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BELTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64012-2165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-331-4000
Provider Business Mailing Address Fax Number:
816-331-3626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17067 S OUTER RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BELTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64012-2165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-331-4000
Provider Business Practice Location Address Fax Number:
816-331-3626
Provider Enumeration Date:
09/19/2005

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: 207Q00000X , with the licence number:  MD R5B55 , 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: 201536331 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1689669301 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100452540A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com