Healthcare Provider Details

I. General information

NPI: 1346653334
Provider Name (Legal Business Name): ANNA WEAVER GRADY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 MIDDLEBURY ST
GOSHEN IN
46528-2956
US

IV. Provider business mailing address

213 MIDDLEBURY ST
GOSHEN IN
46528-2956
US

V. Phone/Fax

Practice location:
  • Phone: 574-534-3300
  • Fax: 574-534-5412
Mailing address:
  • Phone: 574-534-3300
  • Fax: 574-534-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036142675
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01076657A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01076657A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: