Healthcare Provider Details

I. General information

NPI: 1871673491
Provider Name (Legal Business Name): BRADLEY J TISSIER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 N GREENMOUNT RD SUITE 107
OFALLON IL
62269-1953
US

IV. Provider business mailing address

1512 N GREENMOUNT RD SUITE 107
OFALLON IL
62269-1953
US

V. Phone/Fax

Practice location:
  • Phone: 618-628-1717
  • Fax: 618-628-1789
Mailing address:
  • Phone: 618-628-1717
  • Fax: 618-628-1789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: