Provider Demographics
NPI:1225082647
Name:BRADLEY, SHANNON S (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:S
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 N 11TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-1210
Mailing Address - Country:US
Mailing Address - Phone:701-751-2272
Mailing Address - Fax:701-751-0974
Practice Address - Street 1:310 N 10TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4516
Practice Address - Country:US
Practice Address - Phone:701-530-6000
Practice Address - Fax:701-530-6430
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND8469207VG0400X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND160051292OtherMEDICARE RAILROAD
ND11308Medicaid
ND0857780001Medicare NSC
ND20085Medicare ID - Type Unspecified
ND160051292OtherMEDICARE RAILROAD