Provider Demographics
NPI:1265452650
Name:GRAYBEAL ORTHOPEDIC, LLC
Entity Type:Organization
Organization Name:GRAYBEAL ORTHOPEDIC, LLC
Other - Org Name:ANCHOR BRACE AND LIMB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FANN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:423-975-9884
Mailing Address - Street 1:107 E MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-4631
Mailing Address - Country:US
Mailing Address - Phone:423-975-9884
Mailing Address - Fax:423-975-6678
Practice Address - Street 1:107 E MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4631
Practice Address - Country:US
Practice Address - Phone:423-975-9884
Practice Address - Fax:423-975-6678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452173Medicaid
TN003035088OtherBCBS OF TN