Basic Information
| Provider Information | |||||||||
| NPI: | 1366470429 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRADY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 EAST PENN SQUARE | ||||||||
| Address2: | THE WANAMAKER BUILDING 9TH FL | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259538 | ||||||||
| FaxNumber: | 2674259552 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD | ||||||||
| Address2: | CHILDREN'S SURGICAL HOSPITAL OF PHILADELPHIA | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901527 | ||||||||
| FaxNumber: | 2155901501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 06/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | C10006565 | DE | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080S0010X | MD073748L | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001901191-0002 | 05 | PA | MEDICAID |