Basic Information
| Provider Information | |||||||||
| NPI: | 1154357085 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAMPAGNE | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866295 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUDLID AVENUE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447874 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 01/13/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | 056041 | GA | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 10025555600 | 05 | NE | MEDICAID | 2681021 | 05 | OH | MEDICAID | P00385103 | 01 | OH | RAILROAD MEDICARE | OTHER | 363406 | 01 | OH | WELLCARE | OTHER | 745528 | 01 | OH | BUDKEYE | OTHER | 000000221043 | 01 | OH | UNISON | OTHER | 000000503701 | 01 | OH | ANTHEM | OTHER | 056041 | 01 | GA | MEDICAL LICENSE | OTHER | 7396822 | 01 | OH | AETNA | OTHER |