Provider Demographics
NPI:1629172887
Name:GELLETLY, GRACE K (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:K
Last Name:GELLETLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9910 FRANKLIN SQUARE DR # 2110
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4902
Mailing Address - Country:US
Mailing Address - Phone:410-933-5412
Mailing Address - Fax:410-933-1390
Practice Address - Street 1:2700 REMINGTON AVE STE 2000
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211
Practice Address - Country:US
Practice Address - Phone:667-312-2400
Practice Address - Fax:410-367-2203
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD29364208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD371971500Medicaid
MD371971500Medicaid
BW28Medicare ID - Type Unspecified