Provider Demographics
NPI:1982774204
Name:RADFORD ORTHOPEDIC CENTER, P.C.
Entity Type:Organization
Organization Name:RADFORD ORTHOPEDIC CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-639-9315
Mailing Address - Street 1:601 HARVEY ST
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-2339
Mailing Address - Country:US
Mailing Address - Phone:540-639-9315
Mailing Address - Fax:540-731-0860
Practice Address - Street 1:601 HARVEY ST
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-2339
Practice Address - Country:US
Practice Address - Phone:540-639-9315
Practice Address - Fax:540-731-0860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036314207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1033147376OtherNPI
1124056346OtherNPI
VA006430121Medicaid
VA006400205Medicaid
VA0781510001OtherDMERC REGION C
200000382Medicare ID - Type Unspecified
VA0781510001OtherDMERC REGION C
1124056346OtherNPI
VAB05298Medicare UPIN
VA006400205Medicaid