Provider Demographics
NPI:1578686291
Name:GRACE, RENE EARLE (MD)
Entity Type:Individual
Prefix:DR
First Name:RENE
Middle Name:EARLE
Last Name:GRACE
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:P.O. BOX 250
Mailing Address - Street 2:
Mailing Address - City:PINEY POINT
Mailing Address - State:MD
Mailing Address - Zip Code:20674
Mailing Address - Country:US
Mailing Address - Phone:301-994-3366
Mailing Address - Fax:
Practice Address - Street 1:7503 SURRATTS ROAD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20675
Practice Address - Country:US
Practice Address - Phone:301-994-3366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD002259208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC61450Medicare UPIN