Provider Demographics
NPI:1366436677
Name:DRURY, BRADLEY C (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:C
Last Name:DRURY
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 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-5085
Mailing Address - Fax:208-625-5731
Practice Address - Street 1:914 W IRONWOOD DR STE 101
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-625-3500
Practice Address - Fax:208-625-3501
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2024-04-19
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
IDM6015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00367700Medicaid
ID1125879Medicare ID - Type Unspecified
F12628Medicare UPIN