MEDICARE: BERTINA BRADSHAW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	161039939	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043593809
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERTINA BRADSHAW

Provider Business Mailing Address
First Line	:	571 ST. JOSEPH'S BLVD.
Second Line	:	SUITE 102
City	:	ELMIRA
State	:	NY
Zip	:	14901-3230
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	571 ST. JOSEPH'S BLVD.
Second Line	:	SUITE 102
City	:	ELMIRA
State	:	NY
Zip	:	14901-3230
Country	:	US
Telephone Number	:	607-737-5215
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2011
Last Update Date	:	09/27/2011

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Directions to “ BERTINA BRADSHAW ” Practice Location

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