Provider Demographics
NPI:1558351668
Name:GRAVELEY, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:GRAVELEY
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 1:500 YORK RD STE 108
Mailing Address - Street 2:
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-2852
Mailing Address - Country:US
Mailing Address - Phone:215-481-2725
Mailing Address - Fax:215-481-3013
Practice Address - Street 1:500 YORK RD STE 108
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-2852
Practice Address - Country:US
Practice Address - Phone:215-481-2725
Practice Address - Fax:215-481-3013
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2018-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-421514207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101350285-0001Medicaid
PA083864ZCXXMedicare PIN
PA101350285-0001Medicaid
PA416819Medicare PIN
I17763Medicare UPIN
PA083864WHPMedicare PIN