Provider Demographics
NPI:1144024886
Name:ATHERTON, BRODY
Entity type:Individual
Prefix:
First Name:BRODY
Middle Name:
Last Name:ATHERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-2416
Mailing Address - Country:US
Mailing Address - Phone:801-879-5298
Mailing Address - Fax:
Practice Address - Street 1:201 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-2416
Practice Address - Country:US
Practice Address - Phone:801-879-5298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic