Healthcare Provider Details

I. General information

NPI: 1538192364
Provider Name (Legal Business Name): ROGER DEAN GRIDER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E ADAMS ST STE 4
LAGRANGE KY
40031-1278
US

IV. Provider business mailing address

120 E ADAMS ST STE 4
LAGRANGE KY
40031-1278
US

V. Phone/Fax

Practice location:
  • Phone: 502-222-3281
  • Fax: 502-225-5796
Mailing address:
  • Phone: 502-222-3281
  • Fax: 502-225-5796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number19015
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number19015
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number19015
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number19015
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: