Provider Demographics
NPI:1548560543
Name:GRACE LEE WALKER MD PC
Entity Type:Organization
Organization Name:GRACE LEE WALKER MD PC
Other - Org Name:GRACE LEE WALKER, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-232-2683
Mailing Address - Street 1:476 BUCKEYE ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-4079
Mailing Address - Country:US
Mailing Address - Phone:812-232-2683
Mailing Address - Fax:
Practice Address - Street 1:476 BUCKEYE ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-4079
Practice Address - Country:US
Practice Address - Phone:812-232-2683
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031945261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000250977OtherANTHEM
IN100251460Medicaid
C25917Medicare UPIN