Healthcare Provider Details

I. General information

NPI: 1427039635
Provider Name (Legal Business Name): BRADLEY GLENN SMITH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PARK ST GLENS FALLS HOSPITAL
GLENS FALLS NY
12801-4413
US

IV. Provider business mailing address

100 PARK STREET GLENS FALLS HOSPITAL - CREDENTIALING
GLENS FALLS NY
12801-4413
US

V. Phone/Fax

Practice location:
  • Phone: 518-926-5918
  • Fax: 518-926-5917
Mailing address:
  • Phone: 518-926-5924
  • Fax: 518-926-6983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004333
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: