Healthcare Provider Details

I. General information

NPI: 1508861816
Provider Name (Legal Business Name): GRACE FORDE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 02/11/2026
Certification Date: 02/11/2026
Deactivation Date: 08/21/2023
Reactivation Date: 08/31/2023

III. Provider practice location address

170 GREAT NECK RD
GREAT NECK NY
11021-3357
US

IV. Provider business mailing address

170 GREAT NECK RD
GREAT NECK NY
11021-3357
US

V. Phone/Fax

Practice location:
  • Phone: 516-487-4464
  • Fax: 516-487-4950
Mailing address:
  • Phone: 516-487-4464
  • Fax: 516-487-4950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number207390
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number207390
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number207390
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number74667
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number207390
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number207390
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: