Provider Demographics
NPI:1679573786
Name:HENRY, BRADLEY D (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:D
Last Name:HENRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:600 MORRIS ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1409
Mailing Address - Country:US
Mailing Address - Phone:304-388-7130
Mailing Address - Fax:304-388-7136
Practice Address - Street 1:600 MORRIS ST
Practice Address - Street 2:SUITE 102
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1409
Practice Address - Country:US
Practice Address - Phone:304-388-7130
Practice Address - Fax:304-388-7136
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2010-07-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV17873207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0077299-000Medicaid
WVF47318Medicare UPIN
WV0077299-000Medicaid