Healthcare Provider Details

I. General information

NPI: 1699282384
Provider Name (Legal Business Name): ROBERT SAMUEL GRADER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 ANNAPOLIS RD STE 101
ODENTON MD
21113-1672
US

IV. Provider business mailing address

10753 FALLS RD STE 235
LUTHERVILLE MD
21093-4597
US

V. Phone/Fax

Practice location:
  • Phone: 410-874-1700
  • Fax: 410-874-1707
Mailing address:
  • Phone:
  • Fax: 410-847-3838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA4749
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: