Provider Demographics
NPI:1619068061
Name:BRADDY, MICHELLE RAE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:BRADDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RAE
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1207 NETWORK CENTRE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-4632
Mailing Address - Country:US
Mailing Address - Phone:217-347-2707
Mailing Address - Fax:217-347-2827
Practice Address - Street 1:203 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DIETERICH
Practice Address - State:IL
Practice Address - Zip Code:62424-1128
Practice Address - Country:US
Practice Address - Phone:217-925-5730
Practice Address - Fax:217-925-5736
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036120332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D0921285OtherCLIA ID NUMBER
IL036120332OtherILLINOIS PHYSICIAN LICENSE
IL371391171005Medicaid
IL930280OtherHEALTHLINK
IL2523247OtherBLUE CROSS BLUE SHIELD
ILP00790343OtherRAILROAD MEDICARE
IL036120332Medicaid
IL336082411OtherILLINOIS CONTROLLED SUBSTANCE LICENSE
IL371391171005OtherMEDICAID RURAL HEALTH
IL561920OtherMEDICARE GROUP PTAN
IL151351OtherHEALTH ALLIANCE
IL151351OtherHEALTH ALLIANCE
IL14D0921285OtherCLIA ID NUMBER
IL930280OtherHEALTHLINK