Provider Demographics
NPI:1528174489
Name:EGLY, BRADFORD R (DPM)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:R
Last Name:EGLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DWIGHT
Mailing Address - State:IL
Mailing Address - Zip Code:60420
Mailing Address - Country:US
Mailing Address - Phone:815-584-9000
Mailing Address - Fax:815-584-2261
Practice Address - Street 1:108 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DWIGHT
Practice Address - State:IL
Practice Address - Zip Code:60420
Practice Address - Country:US
Practice Address - Phone:815-584-9000
Practice Address - Fax:815-584-2261
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004698213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051548831OtherBCBS AL
FL65410OtherBCBS FLORIDA
ALP00463492OtherRAILROAD MEDICARE
IL016004698Medicaid
AL051005617OtherBCBS AL
AL051005618OtherBCBS AL
AL051538406OtherBCBS AL
AL051005619OtherBCBS AL
AL059202011OtherBCBS AL
AL1528174489Medicare PIN
IL016004698Medicaid