Provider Demographics
NPI:1164640355
Name:GRACEMPRINCETORAIN DPM
Entity Type:Organization
Organization Name:GRACEMPRINCETORAIN DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PRINCE-TORAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:410-674-3707
Mailing Address - Street 1:8379 PINEY ORCHARD PKWY
Mailing Address - Street 2:D
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1508
Mailing Address - Country:US
Mailing Address - Phone:410-674-3707
Mailing Address - Fax:
Practice Address - Street 1:8379 PINEY ORCHARD PKWY
Practice Address - Street 2:D
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1508
Practice Address - Country:US
Practice Address - Phone:410-674-3707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01416213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
V05181Medicare UPIN
MD203PMedicare ID - Type UnspecifiedGROUP NUMBER