MEDICARE: DR. BRADLEY MARK SHORT D.O.

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	208100000X	Physical Medicine & Rehabilitation Physician	C7559	AR

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	:	1568404598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY MARK SHORT D.O.

Provider Business Mailing Address
First Line	:	3905 BROOKEN HILL DR
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-9282
Country	:	US
Telephone Number	:	479-646-3345
Fax Number	:	479-646-6049

Provider Business Practice Location Address
First Line	:	3905 BROOKEN HILL DR
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-9282
Country	:	US
Telephone Number	:	479-646-3345
Fax Number	:	479-646-6049

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

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	12/01/2010

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