Individual
BRADLEY D WILEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1001 E PRIMROSE ST, SPRINGFIELD, MO 65807-5155
(417) 875-3000
(417) 875-3051
Mailing address
PO BOX 9007, SPRINGFIELD, MO 65808-9007
(417) 875-3000
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
111451
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
105284
BLUE CROSS/BLUE SHIELD
—
05
—
208645200
—
MO
Enumeration date
06/14/2006
Last updated
07/05/2012
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