Provider Demographics
NPI:1831745256
Name:BRADY, MARY BETH (MD)
Entity type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:BRADY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8316 LAKE PINE DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-4529
Mailing Address - Country:US
Mailing Address - Phone:248-363-5188
Mailing Address - Fax:248-360-3942
Practice Address - Street 1:8316 LAKE PINE DR
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-4529
Practice Address - Country:US
Practice Address - Phone:248-363-5188
Practice Address - Fax:248-360-3942
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056919207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301056919OtherMEDICAL LICENSE
MI1606355372OtherBLUE CROSS
MI4301056919OtherCONTROLLED SUBSTANCE LICENSE
F59302OtherUPIN
MI2954064Medicaid
MI2954064Medicaid