Healthcare Provider Details

I. General information

NPI: 1245798180
Provider Name (Legal Business Name): BRADLEY PHILLIPS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

4949 S HILLSDALE AVE
MERIDIAN ID
83642-7586
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-2645
  • Fax: 208-381-7170
Mailing address:
  • Phone: 208-706-6400
  • Fax: 208-706-6411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM-17656
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberM-17656
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: