Healthcare Provider Details

I. General information

NPI: 1386609865
Provider Name (Legal Business Name): BRADLEY ALAN MCCUSKER D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BUNKER HILL DR
AITKIN MN
56431
US

IV. Provider business mailing address

200 BUNKER HILL DR
AITKIN MN
56431-1865
US

V. Phone/Fax

Practice location:
  • Phone: 218-927-2157
  • Fax: 218-927-5319
Mailing address:
  • Phone: 218-927-2157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number669
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: