Healthcare Provider Details

I. General information

NPI: 1154577088
Provider Name (Legal Business Name): PAUL BRADLEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 22ND AVE A
MERIDIAN MS
39301-4016
US

IV. Provider business mailing address

PO BOX 2839
MERIDIAN MS
39302-2839
US

V. Phone/Fax

Practice location:
  • Phone: 601-703-3830
  • Fax: 601-553-2069
Mailing address:
  • Phone: 601-703-3480
  • Fax: 601-703-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number22080
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: