Basic Information
| Provider Information | |||||||||
| NPI: | 1396132940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | BRADLEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 S JEFFERSON ST STE 1006 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245715 | ||||||||
| FaxNumber: | 5402245684 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 CRYSTAL SPRING AVE SW STE 203 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240142465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409828204 | ||||||||
| FaxNumber: | 5402241059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2015 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 0101264766 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.