Basic Information
| Provider Information | |||||||||
| NPI: | 1649533878 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 PORTLAND ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737778818 | ||||||||
| FaxNumber: | 5737778819 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 PORTLAND ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737778818 | ||||||||
| FaxNumber: | 5737778819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2012 | ||||||||
| LastUpdateDate: | 08/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 2020041089 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.