Provider Demographics
NPI:1235113002
Name:GRADY, ALICIA (MD)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:GRADY
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 1:5910 HILLANDALE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-1878
Mailing Address - Country:US
Mailing Address - Phone:404-778-8600
Mailing Address - Fax:770-322-7983
Practice Address - Street 1:5910 HILLANDALE DR STE 202
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-1878
Practice Address - Country:US
Practice Address - Phone:404-778-8600
Practice Address - Fax:770-322-7983
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055368207R00000X
GA55368207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA879982349CMedicaid
GAI19933Medicare UPIN
GA879982349CMedicaid
GA202I113807Medicare PIN