Healthcare Provider Details

I. General information

NPI: 1447698469
Provider Name (Legal Business Name): PATRICK DEAN GRACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E BROADWAY AVE
BISMARCK ND
58501-4520
US

IV. Provider business mailing address

3645 S ROME ST STE 204
GILBERT AZ
85297-7338
US

V. Phone/Fax

Practice location:
  • Phone: 701-530-7688
  • Fax:
Mailing address:
  • Phone: 623-777-4747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2015-01028
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME135395
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number16772
License Number StateND
# 4
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number58110
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: