Provider Demographics
NPI:1124030705
Name:BRADY, TERRY M (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:M
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 1:111 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1853
Mailing Address - Country:US
Mailing Address - Phone:309-740-4272
Mailing Address - Fax:
Practice Address - Street 1:2200 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4364
Practice Address - Country:US
Practice Address - Phone:309-662-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360699042085R0202X
IL036-0699042085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC37263Medicare UPIN
L79520Medicare PIN