Provider Demographics
NPI:1972758969
Name:BRADY, JOHN EDWARD (ATC, PES)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:BRADY
Suffix:
Gender:M
Credentials:ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 CEDAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3759
Mailing Address - Country:US
Mailing Address - Phone:810-841-0503
Mailing Address - Fax:
Practice Address - Street 1:3350 GRATIOT BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-2121
Practice Address - Country:US
Practice Address - Phone:810-364-1230
Practice Address - Fax:810-364-0483
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer