Provider Demographics
NPI:1538184759
Name:COLLINS, BRADLEY J (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:COLLINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:117 ELLENFIELD ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4513
Mailing Address - Country:US
Mailing Address - Phone:401-444-4318
Mailing Address - Fax:401-444-6573
Practice Address - Street 1:164 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2853
Practice Address - Country:US
Practice Address - Phone:401-793-2104
Practice Address - Fax:401-793-4047
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD12142207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI31603-7OtherBCBS RI
RI413540OtherBLUECHIP
RI7058655Medicaid
RIAA68866OtherHPHC
RIMD12142OtherMEDICAL LICENSE
RI31603-7OtherBCBS RI