1508277963 NPI number — GRADY PODIATRY LLC

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 1508277963 NPI number — GRADY PODIATRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRADY PODIATRY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1508277963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20800 WESTGATE MALL
Provider Second Line Business Mailing Address:
401
Provider Business Mailing Address City Name:
FAIRVIEW PARK
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44126-1323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-333-7722
Provider Business Mailing Address Fax Number:
440-356-0310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1502 LEAR INDUSTRIAL PKWY
Provider Second Line Business Practice Location Address:
1A
Provider Business Practice Location Address City Name:
AVON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44011-1379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-937-5400
Provider Business Practice Location Address Fax Number:
440-937-5533
Provider Enumeration Date:
05/19/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRADY
Authorized Official First Name:
JACK
Authorized Official Middle Name:
R
Authorized Official Title or Position:
DPM
Authorized Official Telephone Number:
440-937-5400

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  36003597 , 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)