Provider Demographics
NPI:1578666863
Name:BRADY, ROBERT G (PT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:BRADY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2836 STEAMBOAT SPRINGS RUN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-9220
Mailing Address - Country:US
Mailing Address - Phone:920-680-1599
Mailing Address - Fax:
Practice Address - Street 1:330 PACKERLAND DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4816
Practice Address - Country:US
Practice Address - Phone:920-857-1622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251X0800X
WI9918-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9918-024OtherLICENSE NUMBER
WI40375700Medicaid
WI9918-024OtherLICENSE NUMBER
WIK400120519Medicare Oscar/Certification
WI075100095Medicare Oscar/Certification
WI800350043Medicare Oscar/Certification