Healthcare Provider Details

I. General information

NPI: 1669478657
Provider Name (Legal Business Name): MARCELLA W BRADWAY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 NORTH ST SUITE 605
PITTSFIELD MA
01201-4147
US

IV. Provider business mailing address

93 RIDGE AVE
PITTSFIELD MA
01201-1442
US

V. Phone/Fax

Practice location:
  • Phone: 413-447-2745
  • Fax: 413-346-6703
Mailing address:
  • Phone: 413-447-2745
  • Fax: 413-346-6703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number037814
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: