Basic Information
| Provider Information | |||||||||
| NPI: | 1508861816 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | FORDE | ||||||||
| FirstName: | GRACE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 FRANKLIN AVE | ||||||||
| Address2: | |||||||||
| City: | VALLEY STREAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115802145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162566000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 11/04/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | 207390 | NY | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | 207390 | NY | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207LP2900X | 207390 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | 207390 | NY | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LC0200X | 207390 | NY | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01775795 | 05 | NY | MEDICAID |