Provider Demographics
NPI:1508499906
Name:BRADY, ROGER TIMOTHY (DC)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:TIMOTHY
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 1:1051 HELMO AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6032
Mailing Address - Country:US
Mailing Address - Phone:651-447-8811
Mailing Address - Fax:
Practice Address - Street 1:1051 HELMO AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-6032
Practice Address - Country:US
Practice Address - Phone:651-447-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6699111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor