Healthcare Provider Details

I. General information

NPI: 1619068061
Provider Name (Legal Business Name): MICHELLE RAE BRADDY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE RAE COLEMAN M.D.

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S MAIN ST
DIETERICH IL
62424-1128
US

IV. Provider business mailing address

1207 NETWORK CENTRE DR SUITE 3
EFFINGHAM IL
62401-4632
US

V. Phone/Fax

Practice location:
  • Phone: 217-925-5730
  • Fax: 217-925-5736
Mailing address:
  • Phone: 217-347-2707
  • Fax: 217-347-2827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036120332
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: