1336149996 NPI number — MRS. CHANDRA YVETTE GRAVELY MD

Table of content: MRS. CHANDRA YVETTE GRAVELY MD (NPI 1336149996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336149996 NPI number — MRS. CHANDRA YVETTE GRAVELY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAVELY
Provider First Name:
CHANDRA
Provider Middle Name:
YVETTE
Provider Name Prefix Text:
MRS.
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:
1336149996
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4422 CARVER WOODS DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLUE ASH
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45242-5599
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-891-0211
Provider Business Mailing Address Fax Number:
513-792-5945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10700 MONTGOMERY RD
Provider Second Line Business Practice Location Address:
SUITE 311
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-891-0211
Provider Business Practice Location Address Fax Number:
513-792-5945
Provider Enumeration Date:
07/26/2005

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: 207V00000X , with the licence number:  35.062556 , 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: 0936438 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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