MEDICARE: BRADLEY NINE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	15916	WV
2	207R00000X	Internal Medicine Physician	15916	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	00683538	OTHER	WV	BLUE CROSS BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	3001160	OTHER	WV	WORKERS COMPENSATION
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053363127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY NINE MD

Provider Business Mailing Address
First Line	:	3200 MACCORKLE AVE SE
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25304-1297
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3200 MACCORKLE AVE SE
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25304-1297
Country	:	US
Telephone Number	:	304-388-5432
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	10/13/2023

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Directions to “ BRADLEY NINE MD” Practice Location

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