Healthcare Provider Details

I. General information

NPI: 1760476519
Provider Name (Legal Business Name): BRADLEY KEITH BITTLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 S MOUNT AUBURN RD
CAPE GIRARDEAU MO
63703-4914
US

IV. Provider business mailing address

PO BOX 801143
KANSAS CITY MO
64180-1143
US

V. Phone/Fax

Practice location:
  • Phone: 573-331-5544
  • Fax: 573-331-5545
Mailing address:
  • Phone: 573-331-5583
  • Fax: 573-331-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2006023028
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number2006023028
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: