Healthcare Provider Details

I. General information

NPI: 1801110101
Provider Name (Legal Business Name): NICHOLAS COREN BRADBURY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2010
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N 10TH ST
BISMARCK ND
58501-4516
US

IV. Provider business mailing address

PO BOX 2698
BISMARCK ND
58502-2698
US

V. Phone/Fax

Practice location:
  • Phone: 701-530-7500
  • Fax: 701-530-7484
Mailing address:
  • Phone: 701-530-7500
  • Fax: 701-530-7484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMT193226
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number8614430-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number13303
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: