Provider Demographics
NPI:1699881144
Name:CHARLES J BRADAC JR DO INC
Entity type:Organization
Organization Name:CHARLES J BRADAC JR DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRADAC
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:740-676-4623
Mailing Address - Street 1:2 DEER RUN DR
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-9376
Mailing Address - Country:US
Mailing Address - Phone:740-676-4623
Mailing Address - Fax:
Practice Address - Street 1:3000 GUERNSEY ST
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:OH
Practice Address - Zip Code:43906-1540
Practice Address - Country:US
Practice Address - Phone:740-676-4623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005950207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9335551Medicare PIN
WV9363011Medicare PIN
F63033Medicare UPIN