1447248380 NPI number — CHARLES F BRADY DO

Table of content: CHARLES F BRADY DO (NPI 1447248380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447248380 NPI number — CHARLES F BRADY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADY
Provider First Name:
CHARLES
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447248380
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
229 NOGAL PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79915-4516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
903 C NORTH 5TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESTANCIA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-384-2777
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  J8928 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2083X0100X , with the licence number: J8928 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00400M . This is a "BLUE CROSS BLUE SHIELD OF NEW MEXICO" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 000E5032 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 119038103 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 36224 . This is a "PRESBYTERIAN HEALTH PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: PROVP11371 . This is a "MOLINA HEALTHCARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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