Healthcare Provider Details

I. General information

NPI: 1225082647
Provider Name (Legal Business Name): SHANNON S BRADLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 N 11TH ST STE 1
BISMARCK ND
58503-1210
US

IV. Provider business mailing address

3100 N 11TH ST STE 1
BISMARCK ND
58503-1210
US

V. Phone/Fax

Practice location:
  • Phone: 701-751-2272
  • Fax:
Mailing address:
  • Phone: 701-751-2272
  • Fax: 701-751-0974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number8469
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number8469
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: