Healthcare Provider Details

I. General information

NPI: 1497744171
Provider Name (Legal Business Name): EDWARD MICHAEL BRADLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N. 1ST STREET
SPRINGFIELD IL
62702-3749
US

IV. Provider business mailing address

1025 S 6TH ST
SPRINGFIELD IL
62703-2403
US

V. Phone/Fax

Practice location:
  • Phone: 217-528-7541
  • Fax: 217-525-1007
Mailing address:
  • Phone: 217-528-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036063765
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: