Provider Demographics
NPI:1508277963
Name:GRADY PODIATRY LLC
Entity Type:Organization
Organization Name:GRADY PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-937-5400
Mailing Address - Street 1:20800 WESTGATE MALL
Mailing Address - Street 2:401
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-1323
Mailing Address - Country:US
Mailing Address - Phone:440-333-7722
Mailing Address - Fax:440-356-0310
Practice Address - Street 1:1502 LEAR INDUSTRIAL PKWY
Practice Address - Street 2:1A
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-1379
Practice Address - Country:US
Practice Address - Phone:440-937-5400
Practice Address - Fax:440-937-5533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-19
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003597213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6694280002Medicare NSC