Healthcare Provider Details

I. General information

NPI: 1871346064
Provider Name (Legal Business Name): BRADLEY BIBB MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3809 E 9TH ST STE 15
TEXARKANA AR
71854-5818
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 870-621-0080
  • Fax: 870-621-0081
Mailing address:
  • Phone: 870-856-1202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MONYA YORK
Title or Position: CONTROLLER
Credential:
Phone: 870-856-1202