MEDICARE: DOUGLAS L BRADLEY 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	207Q00000X	Family Medicine Physician	MD R5B55	MO

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689669301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS L BRADLEY MD

Provider Business Mailing Address
First Line	:	17067 S OUTER RD
Second Line	:	SUITE 100
City	:	BELTON
State	:	MO
Zip	:	64012-2165
Country	:	US
Telephone Number	:	816-331-4000
Fax Number	:	816-331-3626

Provider Business Practice Location Address
First Line	:	17067 S OUTER RD
Second Line	:	SUITE 100
City	:	BELTON
State	:	MO
Zip	:	64012-2165
Country	:	US
Telephone Number	:	816-331-4000
Fax Number	:	816-331-3626

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

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	01/24/2022

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Directions to “ DOUGLAS L BRADLEY MD” Practice Location

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