Provider Demographics
NPI:1376590372
Name:GRACEY, JACK G (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:G
Last Name:GRACEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:802 NEW HOLLAND AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2163
Mailing Address - Country:US
Mailing Address - Phone:717-358-1305
Mailing Address - Fax:717-291-9634
Practice Address - Street 1:802 NEW HOLLAND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2163
Practice Address - Country:US
Practice Address - Phone:717-358-1305
Practice Address - Fax:717-291-9634
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD028611L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000696452001Medicaid
PAC27420Medicare UPIN
PA000696452001Medicaid