1043275852 NPI number — VICTORIA E GRADY MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043275852 NPI number — VICTORIA E GRADY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRADY
Provider First Name:
VICTORIA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1043275852
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 419402
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-9402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-290-1552
Provider Business Mailing Address Fax Number:
336-774-6872

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8051 PROSPERITY WAY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUTHER GLEN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-448-0198
Provider Business Practice Location Address Fax Number:
804-448-0598
Provider Enumeration Date:
04/18/2006

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: 207R00000X , with the licence number:  95-00597 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 0101053568 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 021044C18 . This is a "MEDICARE PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010339413 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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