Healthcare Provider Details

I. General information

NPI: 1902928047
Provider Name (Legal Business Name): BRADLEY J SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 ENTERPRISE DR FL 2
LIMERICK PA
19468-1224
US

IV. Provider business mailing address

833 CHESTNUT ST STE 520
PHILADELPHIA PA
19107-4430
US

V. Phone/Fax

Practice location:
  • Phone: 800-321-9999
  • Fax:
Mailing address:
  • Phone: 267-592-6191
  • Fax: 267-339-3761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD427776
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: