Provider Demographics
NPI:1457513764
Name:BRADY, GARRY LEE (DO)
Entity type:Individual
Prefix:
First Name:GARRY
Middle Name:LEE
Last Name:BRADY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-3083
Mailing Address - Country:US
Mailing Address - Phone:291-866-0485
Mailing Address - Fax:219-866-0837
Practice Address - Street 1:716 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-3083
Practice Address - Country:US
Practice Address - Phone:219-866-0485
Practice Address - Fax:219-866-0837
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004413A208D00000X
NE7322083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ3233003Medicare PIN
670540001Medicare PIN
000000869308OtherANTHEM
P01314940OtherRAILROAD MEDICARE