MEDICARE: DR. BRADLEY J. G. LARSON MD

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	207RH0003X	Hematology & Oncology Physician	054449	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1194729582	OTHER	GA	NPI NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194729582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY J. G. LARSON MD

Provider Business Mailing Address
First Line	:	531 ROSELANE ST NW STE 710
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060-6975
Country	:	US
Telephone Number	:	678-331-3297
Fax Number	:	678-581-7187

Provider Business Practice Location Address
First Line	:	157 CLINIC AVE
Second Line	:	STE 101
City	:	CARROLLTON
State	:	GA
Zip	:	30117-4413
Country	:	US
Telephone Number	:	770-333-2220
Fax Number	:	678-581-7180

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

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	12/13/2017

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