Healthcare Provider Details

I. General information

NPI: 1124030705
Provider Name (Legal Business Name): TERRY M BRADY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E WASHINGTON ST
BLOOMINGTON IL
61701-4364
US

IV. Provider business mailing address

111 OAKWOOD RD
EAST PEORIA IL
61611-1853
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-3311
  • Fax:
Mailing address:
  • Phone: 309-740-4272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036069904
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036-069904
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: