Provider Demographics
NPI:1710171673
Name:LIDL, GRACE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:MARIE
Last Name:LIDL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 ANDREWS AVE.
Mailing Address - Street 2:LYSTER ARMY HEALTH CLINIC
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-5333
Mailing Address - Country:US
Mailing Address - Phone:334-255-7040
Mailing Address - Fax:334-255-7716
Practice Address - Street 1:301 ANDREWS AVE.
Practice Address - Street 2:LYSTER ARMY HEALTH CLINIC
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362-5333
Practice Address - Country:US
Practice Address - Phone:334-255-7040
Practice Address - Fax:334-255-7716
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider