Healthcare Provider Details

I. General information

NPI: 1578521522
Provider Name (Legal Business Name): BRADLEY HAROLD STAEHLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 WOODLAND ST SUITE 15
HARTFORD CT
06105-2372
US

IV. Provider business mailing address

19 WOODLAND ST SUITE 15
HARTFORD CT
06105-2372
US

V. Phone/Fax

Practice location:
  • Phone: 860-522-1101
  • Fax: 860-549-7092
Mailing address:
  • Phone: 860-522-1101
  • Fax: 860-549-7092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number042159
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: