Basic Information
| Provider Information | |||||||||
| NPI: | 1194846568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | FOSTER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SCIENCE CT | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292039344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032521913 | ||||||||
| FaxNumber: | 8032522330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 08/07/2013 | ||||||||
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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 | 174400000X | 200300124 | NC | N | Other Service Providers | Specialist | 174400000X | 28279 | SC | N | Other Service Providers | Specialist | 174400000X | A96188 | CA | N | Other Service Providers | Specialist | 207ZP0102X | 28279 | SC | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 282795 | 05 | SC | MEDICAID |