Provider Demographics
NPI:1669679007
Name:GRACE, FADY S (MD)
Entity Type:Individual
Prefix:DR
First Name:FADY
Middle Name:S
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:PO BOX 52007
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30355-0007
Mailing Address - Country:US
Mailing Address - Phone:678-397-0060
Mailing Address - Fax:678-397-0065
Practice Address - Street 1:3655 MITCHELL ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-2827
Practice Address - Country:US
Practice Address - Phone:843-716-7255
Practice Address - Fax:843-716-7286
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL30226207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTL30226OtherLICENSE
SC302265Medicaid
SC7762Medicare PIN