Provider Demographics
NPI:1124028170
Name:BRADY, MARK J (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:BRADY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MUNROE FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44262-1638
Mailing Address - Country:US
Mailing Address - Phone:330-686-1300
Mailing Address - Fax:330-686-9809
Practice Address - Street 1:108 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MUNROE FALLS
Practice Address - State:OH
Practice Address - Zip Code:44262-1638
Practice Address - Country:US
Practice Address - Phone:330-686-1300
Practice Address - Fax:330-686-9809
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2011-11-29
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
OH2526111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2349882Medicaid
OH4092761Medicare PIN
OH2349882Medicaid