Basic Information
Provider Information | |||||||||
NPI: | 1548257546 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRADY | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | GREG | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 798 HAUSMAN RD | ||||||||
Address2: | SUITE 310 | ||||||||
City: | ALLENTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 181049108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104320200 | ||||||||
FaxNumber: | 6104320202 | ||||||||
Practice Location | |||||||||
Address1: | 798 HAUSMAN RD | ||||||||
Address2: | SUITE 310 | ||||||||
City: | ALLENTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 181049108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104320200 | ||||||||
FaxNumber: | 6104320202 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2005 | ||||||||
LastUpdateDate: | 01/22/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | OS004677L | PA | N |   | Allopathic & Osteopathic Physicians | Dermatology |   | 207ND0101X | OS004677L | PA | Y |   | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207NS0135X | OS004677L | PA | N |   | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
ID Information
ID | Type | State | Issuer | Description | 735359 | 01 | PA | HIGHMARK BS | OTHER | 50094289 | 01 | PA | CAPITAL BC | OTHER |