Provider Demographics
NPI:1528002045
Name:BRADY, KEVIN MICHAEL (MD)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MICHAEL
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:PO BOX 25033
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92799-5033
Mailing Address - Country:US
Mailing Address - Phone:800-883-7243
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:2700 DOLBEER ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4736
Practice Address - Country:US
Practice Address - Phone:707-445-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND10489207L00000X
WI44931-20207L00000X, 207LC0200X, 207P00000X, 207RC0200X
TXQ0875207L00000X, 207P00000X
MN40235207R00000X
SD5615207R00000X
CAA68632207L00000X
WI44931-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34505900Medicaid
MN749726100Medicaid
ND14207Medicaid
CA00A686320Medicaid
CAP00401288Medicare PIN
MN749726100Medicaid
NDN713465Medicare PIN
ND14207Medicaid
CACF256YMedicare PIN
G72937Medicare UPIN