Provider Demographics
NPI:1578501896
Name:MCGRADY, DOUGLAS J (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:MCGRADY
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:PO BOX 60070
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29419-0070
Mailing Address - Country:US
Mailing Address - Phone:866-759-4528
Mailing Address - Fax:
Practice Address - Street 1:5409 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5069
Practice Address - Country:US
Practice Address - Phone:309-683-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064415207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL220009330OtherRAILROAD MEDICARE
IL0360644151Medicaid
IL220009330OtherRAILROAD MEDICARE
ILL63640Medicare ID - Type Unspecified
ILL35537Medicare ID - Type Unspecified
ILL35527Medicare ID - Type Unspecified
ILL00146Medicare ID - Type Unspecified