1730672171 NPI number — MICHAEL KENNETH GRAUL CT

Table of content: MICHAEL KENNETH GRAUL CT (NPI 1730672171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730672171 NPI number — MICHAEL KENNETH GRAUL CT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAUL
Provider First Name:
MICHAEL
Provider Middle Name:
KENNETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730672171
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 ELLICOTT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARNER ROBINS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31088-3056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-314-5339
Provider Business Mailing Address Fax Number:
740-314-5527

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STEUBENVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43952-2881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-314-5339
Provider Business Practice Location Address Fax Number:
740-314-5527
Provider Enumeration Date:
06/11/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  C1801051TRNE , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0210495 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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