Provider Demographics
NPI:1215434576
Name:BRADLEY, EDWARD
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6650 VIRGILIAN ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70126-2648
Mailing Address - Country:US
Mailing Address - Phone:504-270-4619
Mailing Address - Fax:
Practice Address - Street 1:6650 VIRGILIAN ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70126-2648
Practice Address - Country:US
Practice Address - Phone:504-270-4619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008810870343900000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)