Healthcare Provider Details

I. General information

NPI: 1639516313
Provider Name (Legal Business Name): LAURENCE MARTIN BRADLEY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 HUNTINGTON DR N
ALGONQUIN IL
60102-4419
US

IV. Provider business mailing address

2230 HUNTINGTON DR N
ALGONQUIN IL
60102-4419
US

V. Phone/Fax

Practice location:
  • Phone: 847-603-4146
  • Fax: 847-960-3675
Mailing address:
  • Phone: 847-603-4146
  • Fax: 847-960-3675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number036.142867
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036.142867
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: