NPIMap

Individual provider Active NPI

Brady Cade Blackham, D.O.

  • Family Medicine Physician
  • Gunnison, UT
National Provider Identifier
1679701197
Registry record updated Nov 27, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
8334270-1204 Issued in UT
Practice address
95 East Center Street
Gunnison, UT 84634
Phone
(435) 528-7227
Fax
(435) 528-2175
NPI assigned
Jun 23, 2009
Last updated
Nov 27, 2023By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 27, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X MR-1062 ID
Family Medicine Physician 207Q00000X 8334270-1204 UT Primary

Addresses

Primary practice location

95 East Center Street
Gunnison, UT 84634

Mailing address

1055 N 500 W
Attn: Credentialing
Provo, UT 84604-3321
Phone (801) 354-8225

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address medreview@reverehealth.com Revere Health PC

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in UT
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20121030000087 UT Practitioner - Family Practice 6204086119 Reassigns benefits to 3 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2009
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Revere Health PCGroup PAC ID 7517868508, 407 clinicians

Practice addresses (Care Compare)

64 E 100
Gunnison, UT 84634-7709
Phone (801) 373-4366

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions12
Removal of nail tissue1-10
Removal or shaving of skin growth1-10
Skin biopsy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
MR-1062IDMDFamily Medicine Physician
8334270-1204UTMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Revere Health PC CurrentSince Feb 1, 2013 Accepting new patients
Revere Health PC CurrentSince Feb 1, 2013 Accepting new patients
Gunnison Valley Hospital CurrentSince Jan 1, 2016 Accepting new patients

Locations

1055 N 500 W
Provo, UT 84604
Phone (801) 429-8000

1055 N 500 W
Ste 212
Provo, UT 84604
Phone (801) 374-2362

Interoperability endpoints

  • Direct secure messaging: bradyblackham@cuccu.allscriptsdirect.net

Ownership & related parties

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Mission at Community Living Rehabilitation CenterCenterfield, UT, CCN 465175 Skilled nursing facility Operational/Managerial Control
Adp of the SNF		 May 1, 2024
May 1, 2024
MSM Brigham CityBrigham City, UT, CCN 465165 Skilled nursing facility Corporate Director Jul 1, 2020

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1245715200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1701043200000",
    "number": "1679701197",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1055 N 500 W",
            "address_2": "ATTN: CREDENTIALING",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846043321",
            "telephone_number": "801-354-8225",
            "fax_number": "801-418-0941"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "95 EAST CENTER STREET",
            "city": "GUNNISON",
            "state": "UT",
            "postal_code": "84634",
            "telephone_number": "435-528-7227",
            "fax_number": "435-528-2175"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLACKHAM",
        "first_name": "BRADY",
        "middle_name": "CADE",
        "name_prefix": "Dr.",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2009-06-23",
        "last_updated": "2023-11-27",
        "certification_date": "2020-03-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "ID",
            "license": "MR-1062",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "UT",
            "license": "8334270-1204",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "medreview@reverehealth.com",
            "affiliation": "Y",
            "affiliationName": "Revere Health PC",
            "address_1": "95 East Center Street",
            "city": "Gunnison",
            "state": "UT",
            "country_code": "US",
            "postal_code": "84634",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Gunnison, UT

Sources for this page

Verify at the official NPI Registry.