Provider Demographics
NPI:1598730939
Name:SHAW, GRADY C (MD)
Entity Type:Individual
Prefix:DR
First Name:GRADY
Middle Name:C
Last Name:SHAW
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 1:219 W 6TH AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-5243
Mailing Address - Country:US
Mailing Address - Phone:903-555-0000
Mailing Address - Fax:
Practice Address - Street 1:401 HOSPITAL DR
Practice Address - Street 2:SUITE 140
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-2415
Practice Address - Country:US
Practice Address - Phone:903-872-3005
Practice Address - Fax:903-875-7229
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7158207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX125737006Medicaid
TXDG9311OtherRAILROAD MEDICARE GROUP
TXP00463100OtherRAILROAD MEDICARE
TX00Y226OtherMEDICARE GROUP
C21695Medicare UPIN
TXP00463100OtherRAILROAD MEDICARE