Provider Demographics
NPI:1518949346
Name:GRADY, THOMAS JOSEPH (MD,)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOSEPH
Last Name:GRADY
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HOPE AVE
Mailing Address - Street 2:STE. 207
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-2721
Mailing Address - Country:US
Mailing Address - Phone:781-893-6520
Mailing Address - Fax:781-893-6522
Practice Address - Street 1:20 HOPE AVE
Practice Address - Street 2:STE. 207
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2721
Practice Address - Country:US
Practice Address - Phone:781-893-6520
Practice Address - Fax:781-893-6522
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAA34515208600000X
MA341532086S0129X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2019701Medicaid
AX0126OtherMEDICARE PTAN
MA020909149OtherRAILROAD MEDICARE
MAB18189Medicare ID - Type Unspecified
MA2019701Medicaid