Provider Demographics
NPI:1144330945
Name:DRAKE, BRADLEY RAY
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:RAY
Last Name:DRAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-3720
Mailing Address - Country:US
Mailing Address - Phone:618-242-4554
Mailing Address - Fax:618-242-4653
Practice Address - Street 1:1315 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-3720
Practice Address - Country:US
Practice Address - Phone:618-242-4554
Practice Address - Fax:618-242-4653
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4182010OtherBCBS
IL782220Medicare ID - Type Unspecified