=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265936231
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHAD KAMMER BRADY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2018
-----------------------------------------------------
Last Update Date | 06/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 169 ASHLEY AVENUE ROOM 202 MAIN HOSPITAL, MSC 333
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-792-2300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1336 LEBANON ST
-----------------------------------------------------
City | BLUEFIELD
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24701-4418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-920-7771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | MDO.89954LL
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------