Healthcare Provider Details

I. General information

NPI: 1548784523
Provider Name (Legal Business Name): BRADLEY P CHAMPAGNE, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 07/21/2022
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 DRURY LN
LAFAYETTE LA
70508-5702
US

IV. Provider business mailing address

102 DRURY LN
LAFAYETTE LA
70508-5702
US

V. Phone/Fax

Practice location:
  • Phone: 337-233-0219
  • Fax: 337-233-2418
Mailing address:
  • Phone: 337-233-0219
  • Fax: 337-233-2418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number206155
License Number StateLA

VIII. Authorized Official

Name: SONDRA BERNARD
Title or Position: OFFICE MANAGER
Credential: RHIA
Phone: 337-233-0219