Healthcare Provider Details

I. General information

NPI: 1518968460
Provider Name (Legal Business Name): TODD M. BRADSHAW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MEMORIAL DR STE 1200
BERLIN WI
54923-1243
US

IV. Provider business mailing address

225 MEMORIAL DR STE 1200
BERLIN WI
54923-1243
US

V. Phone/Fax

Practice location:
  • Phone: 920-361-5770
  • Fax: 920-361-5779
Mailing address:
  • Phone: 920-361-5770
  • Fax: 920-361-5779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36541-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number36541-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: