Basic Information
| Provider Information | |||||||||
| NPI: | 1518064583 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADSHAW | ||||||||
| FirstName: | BASCOM | ||||||||
| MiddleName: | KYLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O., M.P.H. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 409075 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303849075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
| FaxNumber: | 8663471426 | ||||||||
| Practice Location | |||||||||
| Address1: | 2191 E JOHNSON AVE | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325146029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504943917 | ||||||||
| FaxNumber: | 8504943960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083A0100X | 02002502A | IN | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Aerospace Medicine | 2084P0800X | OS16451 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | DO.1388 | AL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 02002502A | IN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 73929 | GA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 2018-01630 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1518064583 | 05 | NC | MEDICAID |