Provider Demographics
NPI:1093813750
Name:GRADE, MATTHEW P (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:GRADE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:888 THACKERAY TRL 103
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4342
Mailing Address - Country:US
Mailing Address - Phone:262-354-3744
Mailing Address - Fax:262-354-3748
Practice Address - Street 1:112 HELEN ST
Practice Address - Street 2:
Practice Address - City:SAUK CITY
Practice Address - State:WI
Practice Address - Zip Code:53583-1101
Practice Address - Country:US
Practice Address - Phone:608-643-3351
Practice Address - Fax:608-643-3621
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI21579207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30196900Medicaid
B53185Medicare UPIN
WI30196900Medicaid