Provider Demographics
NPI:1487740049
Name:MARK A. BRADLEY
Entity type:Organization
Organization Name:MARK A. BRADLEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON-MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:276-386-7778
Mailing Address - Street 1:111 ELM STREET
Mailing Address - Street 2:
Mailing Address - City:WEBER CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24290
Mailing Address - Country:US
Mailing Address - Phone:276-386-7778
Mailing Address - Fax:276-386-7857
Practice Address - Street 1:111 ELM STREET
Practice Address - Street 2:
Practice Address - City:WEBER CITY
Practice Address - State:VA
Practice Address - Zip Code:24290
Practice Address - Country:US
Practice Address - Phone:276-386-7778
Practice Address - Fax:276-386-7857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556003111N00000X
VA0101036553207R00000X
VA0024166505363LA2200X
VA0017138087363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08719Medicare ID - Type UnspecifiedMEDICARE