Provider Demographics
NPI:1730196601
Name:BRADFORD FOOT AND ANKLE SPECIALTIES
Entity type:Organization
Organization Name:BRADFORD FOOT AND ANKLE SPECIALTIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:KUMP
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:570-265-7700
Mailing Address - Street 1:PO BOX 376
Mailing Address - Street 2:
Mailing Address - City:WYSOX
Mailing Address - State:PA
Mailing Address - Zip Code:18854-0376
Mailing Address - Country:US
Mailing Address - Phone:570-265-7700
Mailing Address - Fax:570-268-4266
Practice Address - Street 1:1786 GOLDEN MILE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:TOWANDA
Practice Address - State:PA
Practice Address - Zip Code:18848-9733
Practice Address - Country:US
Practice Address - Phone:570-265-7700
Practice Address - Fax:570-268-4266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003249L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025528480001Medicaid
206545OtherMEDICARE PTAN
PA1025528480001Medicaid