Healthcare Provider Details

I. General information

NPI: 1295780872
Provider Name (Legal Business Name): BRADLEY R HAMMERSLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 02/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 W MAIN ST
PERU IN
46970-1747
US

IV. Provider business mailing address

632 W MAIN ST
PERU IN
46970-1747
US

V. Phone/Fax

Practice location:
  • Phone: 765-473-4220
  • Fax: 765-473-4223
Mailing address:
  • Phone: 765-473-4220
  • Fax: 765-473-4223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000906
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number07000906
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: