Basic Information
| Provider Information | |||||||||
| NPI: | 1003015314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | RENAE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1702 SOUTH UNIVERSITY DRIVE | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643100 | ||||||||
| 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: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 52168 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | PT14577 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 14577 | ND | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036940100 | 05 | MN | MEDICAID |