=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871622589
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAY A. BRADLEY LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 W NEW YORK ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46202-5224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-274-0617
-----------------------------------------------------
Fax | 317-278-2041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5433 COTTON BAY DR W
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46254-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-299-6650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 36000217A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------