MEDICARE: WIREGRASS BEHAVIORAL SYSTEMS, PC

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	2084P0800X	Psychiatry Physician	DO.1388	AL

General Provider Information

NPI Number	:	1568840460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WIREGRASS BEHAVIORAL SYSTEMS, PC

Provider Business Mailing Address
First Line	:	1358 STATE HIGHWAY 134 E
Second Line	:
City	:	HEADLAND
State	:	AL
Zip	:	36345-8517
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6501 US HIGHWAY 431 N
Second Line	:
City	:	HEADLAND
State	:	AL
Zip	:	36345-5657
Country	:	US
Telephone Number	:	334-695-2253
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. BASCOM KYLE BRADSHAW
Credential	:	DO
Telephone Number	:	210-454-3703

Provider Enumeration Date	:	05/12/2015
Last Update Date	:	05/12/2015

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