Provider Demographics
NPI:1588646483
Name:MCCOLLUM, BRADY THIRL (DPT, PT)
Entity Type:Individual
Prefix:DR
First Name:BRADY
Middle Name:THIRL
Last Name:MCCOLLUM
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 FAYETTEVILLE RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-6508
Mailing Address - Country:US
Mailing Address - Phone:479-474-0200
Mailing Address - Fax:479-474-0253
Practice Address - Street 1:2215 FAYETTEVILLE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-6508
Practice Address - Country:US
Practice Address - Phone:479-474-0200
Practice Address - Fax:479-474-0253
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2698225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y489Medicare PIN