Provider Demographics
NPI:1396982930
Name:R RALPH BRADLEY M D PC
Entity type:Organization
Organization Name:R RALPH BRADLEY M D PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-268-9672
Mailing Address - Street 1:166 E 5900 S
Mailing Address - Street 2:B-111
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7257
Mailing Address - Country:US
Mailing Address - Phone:801-268-9672
Mailing Address - Fax:801-266-9390
Practice Address - Street 1:166 E 5900 S
Practice Address - Street 2:B-111
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7257
Practice Address - Country:US
Practice Address - Phone:801-268-9672
Practice Address - Fax:801-266-9390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-20
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT162090-1205207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529622566001Medicaid
UT000005857Medicare PIN