=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073690210
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLEY JESS MARCUS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 08/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 171 ASHLEY AVENUE, SUITE 309 MEDICAL UNIVERSITY OF SOUTH CAROLINA, DEPT OF PATH
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29525-8905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-792-3121
-----------------------------------------------------
Fax | 843-792-3537
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5700 SOUTHWYCK BLVD
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43614-1509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-288-8325
-----------------------------------------------------
Fax | 419-866-5453
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZF0201X
-----------------------------------------------------
Taxonomy Name | Forensic Pathology Physician
-----------------------------------------------------
License Number | 25783
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------