Provider Demographics
NPI:1518045293
Name:GRYDER, JEREMY (PT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:GRYDER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7850 STONEGATE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45255
Mailing Address - Country:US
Mailing Address - Phone:513-474-4486
Mailing Address - Fax:
Practice Address - Street 1:3787 WOODRIDGE BLVD.
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014
Practice Address - Country:US
Practice Address - Phone:513-874-1999
Practice Address - Fax:513-874-1653
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 010004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0214940Medicaid
OH366632Medicare ID - Type Unspecified