MEDICARE: R&R 1 LLC

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	036127269	IL

General Provider Information

NPI Number	:	1962815340
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	R&R 1 LLC

Provider Business Mailing Address
First Line	:	9272 CADDYSHACK CIR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63127-1932
Country	:	US
Telephone Number	:	314-718-7276
Fax Number	:

Provider Business Practice Location Address
First Line	:	2071 GOOSE LAKE RD
Second Line	:
City	:	SAUGET
State	:	IL
Zip	:	62206-2822
Country	:	US
Telephone Number	:	618-857-2634
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MATTHEW BRADLEY
Credential	:	MD
Telephone Number	:	314-718-7276

Provider Enumeration Date	:	06/03/2014
Last Update Date	:	06/03/2014

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