Healthcare Provider Details

I. General information

NPI: 1265421440
Provider Name (Legal Business Name): JOHN M BRADY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 NEW SCOTLAND AVE
ALBANY NY
12208-3412
US

IV. Provider business mailing address

47 NEW SCOTLAND AVE
ALBANY NY
12208-3412
US

V. Phone/Fax

Practice location:
  • Phone: 518-262-5076
  • Fax: 518-262-5082
Mailing address:
  • Phone: 518-262-5076
  • Fax: 518-262-5082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003232-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: