MEDICARE: DR. BRADLEY MACGREGOR THOMAS 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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	A72166	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ02606Z	OTHER	CA	BLUE SHIELD ZZ NUMBER

General Provider Information

NPI Number	:	1093822363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY MACGREGOR THOMAS MD

Provider Business Mailing Address
First Line	:	400 S SEPULVEDA BLVD
Second Line	:	SUITE 200
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-6814
Country	:	US
Telephone Number	:	310-546-3461
Fax Number	:	310-546-6481

Provider Business Practice Location Address
First Line	:	400 S SEPULVEDA BLVD
Second Line	:	SUITE 200
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-6814
Country	:	US
Telephone Number	:	310-546-3461
Fax Number	:	310-546-6481

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

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	08/29/2016

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