Provider Demographics
NPI:1750315594
Name:BRADISH, MARY T (CNM)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:T
Last Name:BRADISH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 MONKS AVE
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354
Mailing Address - Country:US
Mailing Address - Phone:815-224-2131
Mailing Address - Fax:815-223-0358
Practice Address - Street 1:2970 CHARTRES ST
Practice Address - Street 2:
Practice Address - City:LASALLE
Practice Address - State:IL
Practice Address - Zip Code:61301
Practice Address - Country:US
Practice Address - Phone:815-223-0196
Practice Address - Fax:815-223-0358
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife