MEDICARE: BRADLEY LAWRENCE TREADWAY ATC

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	2255A2300X	Athletic Trainer	RT003986	PA

General Provider Information

NPI Number	:	1952687493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY LAWRENCE TREADWAY ATC

Provider Business Mailing Address
First Line	:	812 GOSHEN RD
Second Line	:	APT. F28
City	:	WEST CHESTER
State	:	PA
Zip	:	19380-4360
Country	:	US
Telephone Number	:	484-678-1990
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 MONTGOMERY AVE
Second Line	:
City	:	WEST CHESTER
State	:	PA
Zip	:	19380-4456
Country	:	US
Telephone Number	:	484-266-3439
Fax Number	:

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

Provider Enumeration Date	:	10/28/2011
Last Update Date	:	10/28/2011

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