Provider Demographics
NPI:1447542881
Name:MITCHELL, BRADFORD LYLE (MD)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:LYLE
Last Name:MITCHELL
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 1:2415 MCCALLIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-3322
Mailing Address - Country:US
Mailing Address - Phone:423-624-2696
Mailing Address - Fax:423-697-2055
Practice Address - Street 1:2415 MCCALLIE AVENUE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404
Practice Address - Country:US
Practice Address - Phone:423-624-2696
Practice Address - Fax:423-697-2055
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN52304207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
202I086184Medicare PIN