Healthcare Provider Details

I. General information

NPI: 1376882563
Provider Name (Legal Business Name): JERRY ALLEN BRADLEY JR. MD, EDD, MDIV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2013
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 STANTON RD
MOBILE AL
36617-2344
US

IV. Provider business mailing address

PO BOX 746450
ATLANTA GA
30374-6450
US

V. Phone/Fax

Practice location:
  • Phone: 251-471-7207
  • Fax: 251-471-7207
Mailing address:
  • Phone: 866-401-3057
  • Fax: 318-868-6430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberMD.34716
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMD.34716
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: