Healthcare Provider Details

I. General information

NPI: 1477227650
Provider Name (Legal Business Name): CHARLES BRADY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 DELNOR DR STE 400
GENEVA IL
60134-4228
US

IV. Provider business mailing address

351 DELNOR DR STE 400
GENEVA IL
60134-4228
US

V. Phone/Fax

Practice location:
  • Phone: 630-668-0833
  • Fax: 630-208-4373
Mailing address:
  • Phone: 630-668-0833
  • Fax: 630-208-4373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008657
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: