Provider Demographics
NPI:1477716769
Name:GRADY PRIMARY CARE, L.L.C.
Entity Type:Organization
Organization Name:GRADY PRIMARY CARE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:ALLISON
Authorized Official - Last Name:DEKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-378-2214
Mailing Address - Street 1:235 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-2118
Mailing Address - Country:US
Mailing Address - Phone:229-378-2214
Mailing Address - Fax:229-378-2250
Practice Address - Street 1:235 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-2118
Practice Address - Country:US
Practice Address - Phone:229-378-2214
Practice Address - Fax:229-378-2250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA19509261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service