Basic Information
| Provider Information | |||||||||
| NPI: | 1740337542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2055 NORMANDIE DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361112732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3432884624 | ||||||||
| FaxNumber: | 3432803628 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 NORMANDIE DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361112732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342884624 | ||||||||
| FaxNumber: | 3342803628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD26715 | AL | N | Other Service Providers | Specialist | 2085N0700X | MD26715 | AL | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | MD26715 | AL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 009963640 | 05 | AL | MEDICAID |