Basic Information
Provider Information | |||||||||
NPI: | 1871588251 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRADY | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, FACCP, FSCAI | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 SINGLETON RIDGE RD | ||||||||
Address2: | ATTENTION PATIENT ACCOUNTING | ||||||||
City: | CONWAY | ||||||||
State: | SC | ||||||||
PostalCode: | 295266119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432346946 | ||||||||
FaxNumber: | 8432348958 | ||||||||
Practice Location | |||||||||
Address1: | 2376 CYPRESS CIR STE 102 | ||||||||
Address2: |   | ||||||||
City: | CONWAY | ||||||||
State: | SC | ||||||||
PostalCode: | 295268964 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8433478953 | ||||||||
FaxNumber: | 8433470226 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2005 | ||||||||
LastUpdateDate: | 07/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 36435 | SC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 162690 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 162690 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | 36435 | SC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
ID | Type | State | Issuer | Description | 060071214 | 01 | MA | RR MEDICARE | OTHER | GP0965 | 05 | SC |   | MEDICAID | 2011824 | 05 | MA |   | MEDICAID | 02186125 | 05 | NY |   | MEDICAID | 060067418 | 01 | NY | RR MEDICARE | OTHER | CC6110 | 01 | SC | MEDICARE RR | OTHER |