Provider Demographics
NPI:1255422887
Name:GRIDER, JAY SAMUEL (DO, PHD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:SAMUEL
Last Name:GRIDER
Suffix:
Gender:M
Credentials:DO, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 ALUMNI PARK PLZ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4012
Mailing Address - Country:US
Mailing Address - Phone:859-257-7910
Mailing Address - Fax:
Practice Address - Street 1:310 S LIMESTONE
Practice Address - Street 2:SUITE 100A
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-3008
Practice Address - Country:US
Practice Address - Phone:859-323-7246
Practice Address - Fax:859-257-6612
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02674207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64078181Medicaid
0741082Medicare ID - Type Unspecified
I04456Medicare UPIN