Provider Demographics
NPI:1851484075
Name:GRADY, CLYDE
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:GRADY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61448-1339
Mailing Address - Country:US
Mailing Address - Phone:309-289-2335
Mailing Address - Fax:309-289-8196
Practice Address - Street 1:104 S BROAD ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IL
Practice Address - Zip Code:61448-1339
Practice Address - Country:US
Practice Address - Phone:309-289-2335
Practice Address - Fax:309-289-8196
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCB6569Medicare ID - Type UnspecifiedRR GROUP #
G14513Medicare UPIN
ILL64961Medicare ID - Type UnspecifiedINDIVIDUAL #
IL833600Medicare ID - Type UnspecifiedGROUP #