Provider Demographics
NPI:1659497667
Name:GRADY, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
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 1:4201 CATHEDRAL AVE NW
Mailing Address - Street 2:SUITE 114WEST
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-4901
Mailing Address - Country:US
Mailing Address - Phone:202-686-0813
Mailing Address - Fax:202-222-0429
Practice Address - Street 1:4201 CATHEDRAL AVE NW
Practice Address - Street 2:#114W
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-4901
Practice Address - Country:US
Practice Address - Phone:202-686-0813
Practice Address - Fax:202-222-0429
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD15901207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C89243Medicare UPIN
DC00A971M59Medicare PIN