Provider Demographics
NPI:1518965227
Name:BRADY, MARY LEE (DC)
Entity Type:Individual
Prefix:
First Name:MARY LEE
Middle Name:
Last Name:BRADY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8712 FRANKFORD AVE
Mailing Address - Street 2:1A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-1300
Mailing Address - Country:US
Mailing Address - Phone:215-332-7828
Mailing Address - Fax:215-332-7824
Practice Address - Street 1:8712 FRANKFORD AVE
Practice Address - Street 2:1A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-1300
Practice Address - Country:US
Practice Address - Phone:215-332-7828
Practice Address - Fax:215-332-7824
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-002993-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA187672OtherPERSONAL CHOICE
PA1059212OtherKEYSTONE FIRST
PA0061117000OtherKEYSTONE 65
PA187672OtherBLUE CROSS & BLUE SHIELD
PA187672OtherMEDICARE
PA1013353Medicaid
PA0061117000OtherKEYSTONE EAST