Basic Information
| Provider Information | |||||||||
| NPI: | 1518056258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADY | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | TOBIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23340 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631563340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145435200 | ||||||||
| FaxNumber: | 3145435219 | ||||||||
| Practice Location | |||||||||
| Address1: | 10012 KENNERLY RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145435200 | ||||||||
| FaxNumber: | 3145435219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 08/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | R9C27 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 202249520 | 05 | MO | MEDICAID |