Healthcare Provider Details

I. General information

NPI: 1518064583
Provider Name (Legal Business Name): BASCOM KYLE BRADSHAW D.O., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2191 E JOHNSON AVE
PENSACOLA FL
32514-6029
US

IV. Provider business mailing address

PO BOX 409075
ATLANTA GA
30384-9075
US

V. Phone/Fax

Practice location:
  • Phone: 850-494-3917
  • Fax: 850-494-3960
Mailing address:
  • Phone: 615-373-7600
  • Fax: 866-347-1426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number02002502A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO.1388
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number02002502A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number73929
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS16451
License Number StateFL
# 6
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2018-01630
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: