Provider Demographics
NPI:1154357085
Name:CHAMPAGNE, BRADLEY J (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:CHAMPAGNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 WARRENSVILLE CENTER RD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-286-6295
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:11100 EUDLID AVENUE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106
Practice Address - Country:US
Practice Address - Phone:216-844-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056041208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025555600Medicaid
OH2681021Medicaid
OHP00385103OtherRAILROAD MEDICARE
OH363406OtherWELLCARE
OH745528OtherBUDKEYE
OH000000221043OtherUNISON
OH000000503701OtherANTHEM
GA056041OtherMEDICAL LICENSE
OH7396822OtherAETNA
OH000000221043OtherUNISON
OH2681021Medicaid
OH7396822OtherAETNA