Healthcare Provider Details

I. General information

NPI: 1164840328
Provider Name (Legal Business Name): RYAN W BRADSTREET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 PEELER ST
KALAMAZOO MI
49008-2300
US

IV. Provider business mailing address

900 PEELER ST
KALAMAZOO MI
49008-2300
US

V. Phone/Fax

Practice location:
  • Phone: 269-345-8618
  • Fax: 269-345-1508
Mailing address:
  • Phone: 269-345-8618
  • Fax: 269-345-1508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number4301116952
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301116952
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: