Provider Demographics
NPI:1821013723
Name:GRADY, KEVIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:GRADY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:50505 SCHOENHERR RD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3140
Mailing Address - Country:US
Mailing Address - Phone:586-314-0080
Mailing Address - Fax:586-731-6253
Practice Address - Street 1:25319 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3370
Practice Address - Country:US
Practice Address - Phone:586-772-5550
Practice Address - Fax:586-772-1706
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301049952207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1762697Medicaid
MI0E00425OtherBLUE CROSS
MI0E00425OtherBLUE CROSS
MIA77022Medicare UPIN