Healthcare Provider Details

I. General information

NPI: 1477249993
Provider Name (Legal Business Name): JORDAN H BRADSHAW DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 RIVERBEND DR SW
ROME GA
30161-6005
US

IV. Provider business mailing address

420 E 2ND AVE STE 103
ROME GA
30161-3210
US

V. Phone/Fax

Practice location:
  • Phone: 706-291-0084
  • Fax:
Mailing address:
  • Phone: 706-509-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number111625
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: