Healthcare Provider Details

I. General information

NPI: 1801878046
Provider Name (Legal Business Name): ALAN BELMONT BRADLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 05/19/2008
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 Number35042423
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:
Title or Position:
Credential:
Phone: