Provider Demographics
NPI:1346653334
Name:GRADY, ANNA WEAVER (MD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:WEAVER
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 1:213 MIDDLEBURY ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-2956
Mailing Address - Country:US
Mailing Address - Phone:574-534-3300
Mailing Address - Fax:574-534-5412
Practice Address - Street 1:213 MIDDLEBURY ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-2956
Practice Address - Country:US
Practice Address - Phone:574-534-3300
Practice Address - Fax:574-534-5412
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036142675207Q00000X
IN01076657A207V00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036142675OtherLICENSE