MEDICARE: DR. MARK BRADSHAW M.D

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	207R00000X	Internal Medicine Physician	003457	GA
2	207R00000X	Internal Medicine Physician	04-50270	KS
3	208M00000X	Hospitalist Physician	066574	GA

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

General Provider Information

NPI Number	:	1316107428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK BRADSHAW M.D

Provider Business Mailing Address
First Line	:	2 UNIVERSITY PLZ STE 204
Second Line	:
City	:	HACKENSACK
State	:	NJ
Zip	:	07601-6211
Country	:	US
Telephone Number	:	404-367-3014
Fax Number	:

Provider Business Practice Location Address
First Line	:	345 N RIVERVIEW ST STE 412
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67203-4202
Country	:	US
Telephone Number	:	551-295-8223
Fax Number	:

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

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	12/11/2025

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