MEDICARE: DR. BRIAN KEITH KRADEL 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	207L00000X	Anesthesiology Physician	54323	IA
2	207L00000X	Anesthesiology Physician	12932	NV
3	207L00000X	Anesthesiology Physician	ME63649	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	47962	OTHER	AZ	MEDICAL LICENSE

General Provider Information

NPI Number	:	1356370852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN KEITH KRADEL M.D.

Provider Business Mailing Address
First Line	:	726 GULF AIRE DR
Second Line	:
City	:	PORT SAINT JOE
State	:	FL
Zip	:	32456-6123
Country	:	US
Telephone Number	:	850-866-6444
Fax Number	:

Provider Business Practice Location Address
First Line	:	726 GULF AIRE DR
Second Line	:
City	:	PORT SAINT JOE
State	:	FL
Zip	:	32456-6123
Country	:	US
Telephone Number	:	850-866-6444
Fax Number	:

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

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	02/20/2025

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