Provider Demographics
NPI:1306109673
Name:REESE, BRADY (DO)
Entity type:Individual
Prefix:DR
First Name:BRADY
Middle Name:
Last Name:REESE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 12TH ST N STE 2020
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2255
Mailing Address - Country:US
Mailing Address - Phone:320-258-3090
Mailing Address - Fax:320-258-3095
Practice Address - Street 1:3701 12TH ST N STE 2020
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2255
Practice Address - Country:US
Practice Address - Phone:320-258-3090
Practice Address - Fax:320-258-3095
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203552171000000X, 207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN