Provider Demographics
NPI:1982863569
Name:JOHN W. BRADY, JR., M.D. PLLC
Entity Type:Organization
Organization Name:JOHN W. BRADY, JR., M.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:703-369-3376
Mailing Address - Street 1:8650 SUDLEY ROAD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4416
Mailing Address - Country:US
Mailing Address - Phone:703-369-3376
Mailing Address - Fax:703-369-1118
Practice Address - Street 1:8650 SUDLEY ROAD
Practice Address - Street 2:SUITE 310
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4416
Practice Address - Country:US
Practice Address - Phone:703-369-3376
Practice Address - Fax:703-369-1118
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN W. BRADY, JR. M.D. PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-09
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101019666174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C10547OtherPTAN
C10547OtherPTAN