Healthcare Provider Details

I. General information

NPI: 1649680778
Provider Name (Legal Business Name): RORY TYNAN GRACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-5050
  • Fax:
Mailing address:
  • Phone: 919-784-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number25MA10113900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT205831
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2021-01504
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: