Healthcare Provider Details

I. General information

NPI: 1770067589
Provider Name (Legal Business Name): BRADLEY BIBB MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 HIGHWAY 62 412
ASH FLAT AR
72513-9594
US

IV. Provider business mailing address

4196 HIGHWAY 62 412 STE A
HARDY AR
72542-8002
US

V. Phone/Fax

Practice location:
  • Phone: 870-994-7301
  • Fax: 870-994-7488
Mailing address:
  • Phone: 708-561-2028
  • Fax: 501-441-3911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MONYA YORK
Title or Position: ADMINISTRATIVE CREDENTIALING
Credential:
Phone: 573-718-2570