Basic Information
Provider Information | |||||||||
NPI: | 1477553584 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GRADY EMERGENCY PHYSICIANS INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
Address2: |   | ||||||||
City: | KETTERING | ||||||||
State: | OH | ||||||||
PostalCode: | 454295164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8008750136 | ||||||||
FaxNumber: | 9376194150 | ||||||||
Practice Location | |||||||||
Address1: | 561 W CENTRAL AVE | ||||||||
Address2: |   | ||||||||
City: | DELAWARE | ||||||||
State: | OH | ||||||||
PostalCode: | 430151410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403698711 | ||||||||
FaxNumber: | 7403685050 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2005 | ||||||||
LastUpdateDate: | 08/25/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COLE | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8007263627 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 1402097 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | C37015 | 01 | OH | HUMANA GRP PROVIDER# | OTHER | 2457827 | 05 | OH |   | MEDICAID | 000000316994 | 01 | OH | BC/BS GRP PROVIDER NUMBER | OTHER |