Provider Demographics
NPI:1083689533
Name:GRADY, MICHAEL JEROME (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEROME
Last Name:GRADY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 UPLAND TRL
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30054-2923
Mailing Address - Country:US
Mailing Address - Phone:770-483-2368
Mailing Address - Fax:770-785-5080
Practice Address - Street 1:1311 MILSTEAD AVE NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3829
Practice Address - Country:US
Practice Address - Phone:770-483-2368
Practice Address - Fax:770-785-5080
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029875174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA16BDDJSMedicare ID - Type Unspecified
GAD45457Medicare UPIN