Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 08001899A | IN |
Y | 111NN0400X | Neurology | 08001899A | IN |
NPI | 1912945536 |
---|---|
Provider Name | Bradley R Ralston |
First Address | Indianapolis, IN 46260-1842 |
Second Address | Indianapolis, IN 46260-1842 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2006 |
Last Update Date | 27/09/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000198956 | BLUE CROSS/BLUE SHIELD (01) | |
200363370A | (05) | IN |