MEDICARE: BRADLEY BRASK R

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	247100000X	Radiologic Technologist

General Provider Information

NPI Number	:	1407053804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY BRASK R

Provider Business Mailing Address
First Line	:	2 N CENTRAL AVE
Second Line	:	SUITE 170-284
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2322
Country	:	US
Telephone Number	:	307-690-0420
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 N CENTRAL AVE
Second Line	:	SUITE 170-284
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2322
Country	:	US
Telephone Number	:	307-690-0420
Fax Number	:

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

Provider Enumeration Date	:	06/29/2007
Last Update Date	:	07/08/2007

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