Provider Demographics
NPI:1568438604
Name:GRADY, ROBERT E JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:GRADY
Suffix:JR
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:PO BOX 1321
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57101-1321
Mailing Address - Country:US
Mailing Address - Phone:605-338-5488
Mailing Address - Fax:605-373-9971
Practice Address - Street 1:1305 W 18TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0401
Practice Address - Country:US
Practice Address - Phone:605-338-5488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4704207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0529438Medicaid
AR150724001Medicaid
MN64G78GROtherBCBS
MN756223300Medicaid
SD0006991OtherBCBS
MO207219205Medicaid
SD5707250Medicaid
TX1632879-01Medicaid
IA0529438Medicaid
AR150724001Medicaid
MN64G78GROtherBCBS