Basic Information
| Provider Information | |||||||||
| NPI: | 1528002045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25033 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927995033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008837243 | ||||||||
| FaxNumber: | 7146471245 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 DOLBEER ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955014736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074458121 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 10489 | ND | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 44931-20 | WI | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | Q0875 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LC0200X | 44931-20 | WI | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207P00000X | 44931-20 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 40235 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 5615 | SD | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 44931-20 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207L00000X | A68632 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207P00000X | Q0875 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 44931-020 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34505900 | 05 | WI | MEDICAID | 749726100 | 05 | MN | MEDICAID | 14207 | 05 | ND | MEDICAID | 00A686320 | 05 | CA | MEDICAID |