Provider Demographics
NPI:1003856352
Name:BRADY, PETER K (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:K
Last Name:BRADY
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:PO BOX 601495
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1495
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:730 STONY LANDING RD
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-2904
Practice Address - Country:US
Practice Address - Phone:843-720-8363
Practice Address - Fax:843-761-7881
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21589207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC215895Medicaid
F40706Medicare UPIN
SC215895Medicaid
SC930114131Medicare PIN
SCF407062987Medicare PIN