Provider Demographics
NPI:1154515013
Name:PETER S. BRADSHAW M.D.
Entity type:Organization
Organization Name:PETER S. BRADSHAW M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:SHEWELL
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-459-3341
Mailing Address - Street 1:77 E MERRIMACK ST
Mailing Address - Street 2:SUITE 15
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-1251
Mailing Address - Country:US
Mailing Address - Phone:978-459-3341
Mailing Address - Fax:978-459-5344
Practice Address - Street 1:77 E MERRIMACK ST
Practice Address - Street 2:SUITE 15
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1251
Practice Address - Country:US
Practice Address - Phone:978-459-3341
Practice Address - Fax:978-459-5344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2055074Medicaid
MAM17561OtherBLUE CROSS/BLUE SHIELD