Healthcare Provider Details

I. General information

NPI: 1467983908
Provider Name (Legal Business Name): BRADLEY RAYMOND WITHERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2017
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST
LEXINGTON KY
40536-7001
US

IV. Provider business mailing address

800 ROSE STREET ANESTHESIOLOGY
LEXINGTON KY
40536-0001
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5956
  • Fax: 859-323-1080
Mailing address:
  • Phone: 859-218-0069
  • Fax: 859-323-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberR4611
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number55219
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: