MEDICARE: MARCELLA W BRADWAY 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	208C00000X	Colon & Rectal Surgery Physician	037814	CT

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	:	1669478657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCELLA W BRADWAY M.D.

Provider Business Mailing Address
First Line	:	93 RIDGE AVE
Second Line	:
City	:	PITTSFIELD
State	:	MA
Zip	:	01201-1442
Country	:	US
Telephone Number	:	413-447-2745
Fax Number	:	413-346-6703

Provider Business Practice Location Address
First Line	:	777 NORTH ST
Second Line	:	SUITE 605
City	:	PITTSFIELD
State	:	MA
Zip	:	01201-4147
Country	:	US
Telephone Number	:	413-447-2745
Fax Number	:	413-346-6703

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

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	06/26/2012

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