Provider Demographics
NPI:1699819227
Name:GRACE UROLOGICAL INC
Entity Type:Organization
Organization Name:GRACE UROLOGICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:SF
Authorized Official - Last Name:DALY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-257-4265
Mailing Address - Street 1:191 CLARK AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-3400
Mailing Address - Country:US
Mailing Address - Phone:802-257-4265
Mailing Address - Fax:802-258-3809
Practice Address - Street 1:191 CLARK AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-3400
Practice Address - Country:US
Practice Address - Phone:802-257-4265
Practice Address - Fax:802-258-3809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT420008109208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN0579Medicaid
VT0VN0579Medicaid