Provider Demographics
NPI:1821140112
Name:WILLIAMS, BRADY RONALD (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADY
Middle Name:RONALD
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 COLUMBIA CTR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2561
Mailing Address - Country:US
Mailing Address - Phone:618-281-4111
Mailing Address - Fax:618-281-4112
Practice Address - Street 1:634 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1438
Practice Address - Country:US
Practice Address - Phone:618-281-4111
Practice Address - Fax:618-281-4112
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010632111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV09040Medicare UPIN