Healthcare Provider Details

I. General information

NPI: 1568417368
Provider Name (Legal Business Name): BRADFORD NOLL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

58 HATHAWAY AVE
BEVERLY MA
01915-1438
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7001
  • Fax: 260-407-8008
Mailing address:
  • Phone: 978-927-9312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: