Provider Demographics
NPI:1053561993
Name:EVERLY, BRADLEY PAUL (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:PAUL
Last Name:EVERLY
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 1:1900 INDIAN WOOD CIR STE 202B
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-4039
Mailing Address - Country:US
Mailing Address - Phone:419-578-8594
Mailing Address - Fax:
Practice Address - Street 1:1900 INDIAN WOOD CIR STE 202B
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537
Practice Address - Country:US
Practice Address - Phone:419-578-8594
Practice Address - Fax:855-618-2622
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-097443207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #
OH0050614Medicaid
OH2551671OtherPARTNERS PHYSICIAN GROUP MEDICAID #
OH9338635OtherPARTNERS PHYSICIAN GROUP MEDICARE #
OH0050614Medicaid