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General NPI Number Information
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NPI Number | 1013985613
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Entity Type | Individual
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Provider Name | BRADLEY C. BRUSH A.T.C., C.S.C.S.
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Gender | Male
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Dates
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Enumeration Date | 03/09/2006
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Last Update Date | 12/22/2008
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Provider Practice Location Address
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Address Line | 305 W JACKSON ST SUITE LL02
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City | CARBONDALE
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State | IL
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Zip | 62901-1474
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Country | US
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Telephone | 618-549-0721
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Fax | 618-529-0403
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Provider Business Mailing Address
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Address Line | 507 S GREEN ST
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City | ANNA
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State | IL
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Zip | 62906-1103
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Country | US
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Telephone | 618-833-4441
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 096-000308
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License Number State | IL
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