Healthcare Provider Details

I. General information

NPI: 1962400754
Provider Name (Legal Business Name): THOMAS AUSTIN GRADY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 WEST SIXTH STREET, STE 270 PHYSICIAN CARE PC
OSWEGO NY
13126
US

IV. Provider business mailing address

110 W 6TH ST
OSWEGO NY
13126-2507
US

V. Phone/Fax

Practice location:
  • Phone: 315-349-5752
  • Fax: 315-349-5769
Mailing address:
  • Phone: 315-349-5511
  • Fax: 315-349-5921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number211331
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: