Provider Demographics
NPI:1952566036
Name:GRADES PODIATRIC GROUP, PLLC
Entity Type:Organization
Organization Name:GRADES PODIATRIC GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUERCY
Authorized Official - Middle Name:
Authorized Official - Last Name:SAINT-PHARD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:269-277-5040
Mailing Address - Street 1:185 E MAIN ST STE 408
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-4456
Mailing Address - Country:US
Mailing Address - Phone:269-277-5040
Mailing Address - Fax:269-277-5010
Practice Address - Street 1:185 E MAIN ST STE 408
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-4456
Practice Address - Country:US
Practice Address - Phone:269-277-5040
Practice Address - Fax:269-277-5010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002223213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI134891750Medicaid
MIP03540002Medicare PIN
MIOP63170Medicare PIN
MI134891750Medicaid