Healthcare Provider Details

I. General information

NPI: 1548264385
Provider Name (Legal Business Name): BRAD E. MCCOLLOM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8005 BAY ST STE 5
SEBASTIAN FL
32958-3244
US

IV. Provider business mailing address

8005 BAY ST STE 5
SEBASTIAN FL
32958-3244
US

V. Phone/Fax

Practice location:
  • Phone: 772-581-8075
  • Fax: 772-581-8031
Mailing address:
  • Phone: 772-581-8075
  • Fax: 772-581-8031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberOS9270
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: