Provider Demographics
NPI:1518079987
Name:BREADY, RANDALL J (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:J
Last Name:BREADY
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 1:3340 NORTH CENTER ST #800
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7406
Mailing Address - Country:US
Mailing Address - Phone:801-990-1911
Mailing Address - Fax:801-990-1912
Practice Address - Street 1:3741 W 12600 S
Practice Address - Street 2:RIVERTON HOSPITAL
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065
Practice Address - Country:US
Practice Address - Phone:801-285-4000
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261323-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118951400Medicaid
UT1502954OtherUMWA
UTQM0000075886OtherALTIUS
UT870545614BR2OtherEDUCATORS MUTUAL
UT2090168OtherUNITED HEALTHCARE
ID806744000Medicaid
AZ825747Medicaid
NV100501895Medicaid
UT99457OtherHEALTHY U
UT107007689102OtherIHC
UT305405OtherDESERET MUTUAL
UT73550OtherPEHP
UTPRA04262OtherMOLINA
ID806744000Medicaid
WY118951400Medicaid
UT1502954OtherUMWA