Provider Demographics
NPI:1023004728
Name:GRIAS-RADWANSKI, SOPHIA (MD)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:GRIAS-RADWANSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29275 NORTHWESTERN HWY
Mailing Address - Street 2:STE 100
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1044
Mailing Address - Country:US
Mailing Address - Phone:877-784-3667
Mailing Address - Fax:248-784-3743
Practice Address - Street 1:29275 NORTHWESTERN HWY
Practice Address - Street 2:STE 100
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1044
Practice Address - Country:US
Practice Address - Phone:877-784-3667
Practice Address - Fax:248-784-3743
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072565174400000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH73391Medicare UPIN
MI0Q26462Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER