Healthcare Provider Details

I. General information

NPI: 1023214509
Provider Name (Legal Business Name): BRADLEY R DYER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 10/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 FARAON ST MS 1020 DIVISION OF GENERAL AND GERIATRIC MEDICINE UNIV
SAINT JOSEPH MO
64506-3488
US

IV. Provider business mailing address

5325 FARAON ST
SAINT JOSEPH MO
64506-3488
US

V. Phone/Fax

Practice location:
  • Phone: 816-271-6406
  • Fax:
Mailing address:
  • Phone: 816-271-6406
  • Fax: 816-271-7986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2015000100
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number05-35676
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2015000100
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: