Provider Demographics
NPI:1558567123
Name:GRACE PARADELA MD PC
Entity Type:Organization
Organization Name:GRACE PARADELA MD PC
Other - Org Name:DIXIE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-688-0759
Mailing Address - Street 1:292 S 1470 E STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-1764
Mailing Address - Country:US
Mailing Address - Phone:435-688-0759
Mailing Address - Fax:435-656-0491
Practice Address - Street 1:292 S 1470 E STE 200
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-1764
Practice Address - Country:US
Practice Address - Phone:435-688-0759
Practice Address - Fax:435-656-0491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4998928-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT143045912001Medicaid
UT143045912001Medicaid