=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043453707
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | B C STUFFLEBAM, MD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2009
-----------------------------------------------------
Last Update Date | 04/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 629 SABLE DR
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62801-4472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-533-0727
-----------------------------------------------------
Fax | 618-533-1464
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 629 SABLE DR
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62801-4472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-533-0727
-----------------------------------------------------
Fax | 618-533-1464
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | BRADLEY CHRISTIAN STUFFLEBAM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 618-533-0727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 036058847
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------