Healthcare Provider Details

I. General information

NPI: 1669055810
Provider Name (Legal Business Name): GRATEFUL THERAPEUTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 THOMAS JOHNSON DR STE 170
FREDERICK MD
21702-4530
US

IV. Provider business mailing address

4 ESTHER ANN WAY
REISTERSTOWN MD
21136-5846
US

V. Phone/Fax

Practice location:
  • Phone: 240-556-5748
  • Fax:
Mailing address:
  • Phone: 908-653-9399
  • Fax: 908-653-9305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN FLAKS
Title or Position: OWNER
Credential: DO
Phone: 908-653-9399