Provider Demographics
NPI:1598741886
Name:GRADY, PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:GRADY
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 1:11781 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:SUITE 550
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3309
Mailing Address - Country:US
Mailing Address - Phone:571-777-5102
Mailing Address - Fax:703-563-6256
Practice Address - Street 1:746 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1624
Practice Address - Country:US
Practice Address - Phone:570-346-7797
Practice Address - Fax:570-342-9802
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032741E207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011278280001Medicaid
PA050015093OtherRR MEDICARE
PA146933F4NMedicare PIN
PA050015093OtherRR MEDICARE
PA146933Medicare PIN