Basic Information
| Provider Information | |||||||||
| NPI: | 1255746731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADBURN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7174 VASSAR RD | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484397405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108459094 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 850 PETER BRYCE BLVD | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354017457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053481770 | ||||||||
| FaxNumber: | 2053489868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2014 | ||||||||
| LastUpdateDate: | 09/26/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO1878 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 5101021401 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.