Healthcare Provider Details

I. General information

NPI: 1144290321
Provider Name (Legal Business Name): BRADLEY INGRAM PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 03/07/2023
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22911 JEFFERSON BLVD
SMITHSBURG MD
21783-1617
US

IV. Provider business mailing address

11110 MEDICAL CAMPUS RD SUITE 229
HAGERSTOWN MD
21742-6700
US

V. Phone/Fax

Practice location:
  • Phone: 301-824-3343
  • Fax: 301-824-6323
Mailing address:
  • Phone: 301-665-4526
  • Fax: 301-665-4521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110001879
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0003519
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: