MEDICARE: DR. THOMAS LANE BRADBURY JR. 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	207XS0114X	Adult Reconstructive Orthopaedic Surgery Physician	200600296	NC
2	207XS0114X	Adult Reconstructive Orthopaedic Surgery Physician	059130	GA

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	:	1720019698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS LANE BRADBURY JR. MD

Provider Business Mailing Address
First Line	:	59 EXECUTIVE PARK S
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30329-2208
Country	:	US
Telephone Number	:	404-778-7188
Fax Number	:	404-778-7036

Provider Business Practice Location Address
First Line	:	59 EXECUTIVE PARK S
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30329-2208
Country	:	US
Telephone Number	:	404-778-7188
Fax Number	:	404-778-7036

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	02/01/2015

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