Provider Demographics
NPI:1093723322
Name:GRAD, CHARLES THOMAS SR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:THOMAS
Last Name:GRAD
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 STONYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-1166
Mailing Address - Country:US
Mailing Address - Phone:570-586-9578
Mailing Address - Fax:
Practice Address - Street 1:201 SMALLACOMBE DR
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-2616
Practice Address - Country:US
Practice Address - Phone:570-961-0171
Practice Address - Fax:570-207-2411
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014268E207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD014268EOtherMD LICENSE
PA0006769880001Medicaid
094227Medicare ID - Type Unspecified
PA0006769880001Medicaid