Provider Demographics
NPI:1063798429
Name:SAGE, BRADLEY W (LAT, ATC, MSED)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:W
Last Name:SAGE
Suffix:
Gender:M
Credentials:LAT, ATC, MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2737 E BRESSINGHAM WAY
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4168
Mailing Address - Country:US
Mailing Address - Phone:814-746-2696
Mailing Address - Fax:
Practice Address - Street 1:2737 E BRESSINGHAM WAY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4168
Practice Address - Country:US
Practice Address - Phone:814-746-2696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002345A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN36002345AOtherATHLETIC TRAINING LICENSE