MICHELLE RAE BRADDY (NPI# 1619068061) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1619068061 |
| Entity Type | Individual |
| Full Name | MICHELLE RAE BRADDY |
| Other Name | MICHELLE RAE COLEMAN |
| Credential | M.D. |
| Practice Address |
203 S Main St Dieterich IL 62424-1128 |
| Mailing Address |
1207 Network Centre Dr Suite 3 Effingham IL 62401-4632 |
| Practice Telephone | 2179255730 |
| Practice Fax Number | 2179255736 |
| Mailing Telephone | 2173472707 |
| Mailing Fax Number | 2173472827 |
| Enumeration Date | 2006-09-28 |
| Last Update Date | 2014-04-18 |
| Gender Code | F |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 207Q00000X | Family Medicine | 036120332 | IL | Allopathic & Osteopathic Physicians |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| IL | CLIA ID NUMBER | 14D0921285 | 01 |
| IL | ILLINOIS PHYSICIAN LICENSE | 036120332 | 01 |
| IL | BLUE CROSS BLUE SHIELD | 2523247 | 01 |
| IL | 371391171005 | 05 | |
| IL | RAILROAD MEDICARE | P00790343 | 01 |
| IL | 036120332 | 05 | |
| IL | HEALTH ALLIANCE | 151351 | 01 |
| IL | ILLINOIS CONTROLLED SUBSTANCE LICENSE | 336082411 | 01 |
| IL | MEDICARE GROUP PTAN | 561920 | 01 |
| DEA | BB9934541 | 01 | |
| IL | MEDICAID RURAL HEALTH | 371391171005 | 01 |
| IL | HEALTHLINK | 930280 | 01 |
| Street Address |
203 S MAIN ST |
| City | DIETERICH |
| State | IL |
| Zip Code | 62424-1128 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1922559897 | Poehlers Pharmacy LLC | Pharmacy | 203 S Main St, Suite A, Dieterich, IL 62424-1128 | 2016-10-17 |
| 1972892313 | Jennifer Elizabeth Kistner | Nurse Practitioner | 203 S Main St, Dieterich, IL 62424 | 2011-04-06 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1437600897 | Angela Koester | Occupational Therapy Assistant | 5250 N 100th St, Dieterich, IL 62424 | 2016-10-20 |
| 1568619088 | Mid-illinois Medical Care Associates, LLC | Clinic/Center | 203 S. Main St., Dieterich, IL 62424 | 2008-08-27 |
| 1598873176 | Dieterich Comm Unit 30 | Local Education Agency (LEA) | 205 S. Pine, Dieterich, IL 62424 | 2006-08-25 |
| 1467754622 | Michelle Schnepper | Behavioral Analyst | 308 Prairie Dr, Dieterich, IL 62424-1127 | 2010-11-21 |
| 1750507422 | Stephanie Shadle | Developmental Therapist | 304 Prairie Dr, Dieterich, IL 62424-1127 | 2007-04-18 |
| 1346694841 | Traci Walk | Physical Therapy Assistant | 20379 E 1100th Ave, Dieterich, IL 62424-2114 | 2016-04-20 |
| 1477967925 | Diana Williams | Physical Therapy Assistant | 20234 E 1000th Ave, Dieterich, IL 62424-2142 | 2014-06-12 |
| 1528134608 | Keli J. Dhom | Physical Therapist | 19460 E 1150th Ave, Dieterich, IL 62424-2150 | 2006-11-28 |
| Taxonomy Code | 207Q00000X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Family Medicine |
| Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity. |
| Notes: Source: American Board of Family Medicine [1/1/2007: changed title; 7/1/2007: added definition, added source; 7/1/2017: modified definition] - Note: The American Osteopathic Board of Family Physicians certification includes extensive use of Osteopathic Manipulative Treatment (OMT), which integrates the biological, clinical, and behavioral sciences. - Additional Resources: American Board of Family Medicine, www.theabfm.org. American Osteopathic Board of Family Physicians, www.osteopathic.org/certification - Board certification for Medical Doctors (MDs) is provided by the American Board of Family Medicine. Board certification for Doctors of Osteopathy (DOs) is provided by the American Osteopathic Board of Family Physicians or the American Board of Family Medicine. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1053911495 | Moataz Barkat | Family Medicine | 3315 W 66th Pl, Chicago, IL 60629-3427 | 2020-10-26 |
| 1558969964 | Nicole Kerner | Family Medicine | 310 Brandy Dr, Mackinaw, IL 61755-9707 | 2020-10-16 |
| 1285232991 | Healthy Medical Inc | Family Medicine | 535 N. East St., Suite A, Bradley, IL 60915 | 2020-10-14 |
| 1558976589 | Jasmine Ashley Fowler | Family Medicine | 2416 N Lotus Ave, Chicago, IL 60639-1435 | 2020-09-15 |
| 1790390805 | Kimberly Hannah Kupferberg | Family Medicine | 1103 Schaeffer Rd, Long Grove, IL 60047-5153 | 2020-09-15 |
| 1194330977 | Home Doctors for You | Family Medicine | 670 Illinois Blvd, Hoffman Est, IL 60169-3363 | 2020-09-09 |
| 1245844489 | Jovita Zalwango Nassolo | Family Medicine | 116 1/2 N Benton St Apt 2d, Woodstock, IL 60098-3272 | 2020-09-04 |
| 1720699176 | Healing Hands Resource Center Streator | Family Medicine | 2128 S Central Park Ave, Chicago, IL 60623-3113 | 2020-08-10 |
| 1417565755 | Ghr Total Health and Consulting | Family Medicine | 11336 Mckenna Dr, Frankfort, IL 60423-8096 | 2020-07-22 |
| 1285251892 | Soe Lwin Oo | Family Medicine | 1625 E 75th St # 1, Chicago, IL 60649-3603 | 2020-06-30 |
| Find all providers with the same taxonomy | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.