Provider Demographics
NPI:1477227650
Name:BRADY, CHARLES (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BRADY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 DELNOR DR STE 400
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4228
Mailing Address - Country:US
Mailing Address - Phone:630-668-0833
Mailing Address - Fax:630-208-4373
Practice Address - Street 1:351 DELNOR DR STE 400
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4228
Practice Address - Country:US
Practice Address - Phone:630-668-0833
Practice Address - Fax:630-208-4373
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008657363A00000X
IL085.008657363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant