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 1:703 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KOUTS
Mailing Address - State:IN
Mailing Address - Zip Code:46347-9692
Mailing Address - Country:US
Mailing Address - Phone:219-766-3131
Mailing Address - Fax:219-766-0303
Practice Address - Street 1:703 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KOUTS
Practice Address - State:IN
Practice Address - Zip Code:46347-9692
Practice Address - Country:US
Practice Address - Phone:219-766-3131
Practice Address - Fax:219-766-0303
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2017-05-09
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