Healthcare Provider Details

I. General information

NPI: 1043894132
Provider Name (Legal Business Name): BRADY W IBA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 S MATTIS AVE
CHAMPAIGN IL
61821-5923
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2529
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-2855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number8368
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036179155
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: