Basic Information
Provider Information
NPI: 1003015314
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BRADLEY
FirstName: MICHELLE
MiddleName: RENAE
NamePrefix: DR.
NameSuffix:  
Credential: DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1702 SOUTH UNIVERSITY DRIVE
Address2:  
City: FARGO
State: ND
PostalCode: 581034940
CountryCode: US
TelephoneNumber: (701) 364-3100
FaxNumber: 3202020756
Practice Location
Address1: 4110 51ST AVE S
Address2:  
City: FARGO
State: ND
PostalCode: 581047776
CountryCode: US
TelephoneNumber: 7013643100
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/16/2007
LastUpdateDate: 07/25/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X14577NDY Allopathic & Osteopathic PhysiciansFamily Medicine 
207Q00000XPT14577NDN Allopathic & Osteopathic PhysiciansFamily Medicine 
207Q00000X52168MNN Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
03694010005MN MEDICAID


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