Healthcare Provider Details

I. General information

NPI: 1659543676
Provider Name (Legal Business Name): ALAN B BRADLEY MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 E ELM ST SUITE 204
LIMA OH
45804-2850
US

IV. Provider business mailing address

1220 E ELM ST SUITE 204
LIMA OH
45804-2850
US

V. Phone/Fax

Practice location:
  • Phone: 419-224-2632
  • Fax: 419-222-2731
Mailing address:
  • Phone: 419-224-2632
  • Fax: 419-222-2731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number35042423B
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0492864
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: DR. ALAN B BRADLEY
Title or Position: OWNER
Credential: MD
Phone: 419-224-2632