Individual
JACK BRADLEY ROYAL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
902 N 7TH ST, CORDELE, GA 31015-3234
(229) 276-3100
Mailing address
307 E 3RD AVE, CORDELE, GA 31015-3208
(229) 271-4656
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
TRN17253
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003180038C
—
GA
Enumeration date
06/27/2012
Last updated
03/21/2021
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