Healthcare Provider Details

I. General information

NPI: 1285560490
Provider Name (Legal Business Name): ENNOBLE HC KY II PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 UNIVERSITY PLZ
HACKENSACK NJ
07601-6202
US

IV. Provider business mailing address

2 UNIVERSITY PLZ
HACKENSACK NJ
07601-6202
US

V. Phone/Fax

Practice location:
  • Phone: 551-295-8223
  • Fax:
Mailing address:
  • Phone: 551-295-8223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK BRADSHAW
Title or Position: OWNER
Credential: MD
Phone: 678-665-2618