Basic Information
| Provider Information | |||||||||
| NPI: | 1639294259 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E THIRD STREET MCL2CRED | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187863146 | ||||||||
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| Practice Location | |||||||||
| Address1: | ESSENTIA HEALTH SOUTH UNIVERSITY CLINIC | ||||||||
| Address2: | 1702 UNIVERSITY DRIVE SOUTH | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 03/26/2019 | ||||||||
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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 | 208100000X | 52167 | MN | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | PT14574 | ND | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 14574 | ND | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 864638100 | 05 | MN | MEDICAID |