Healthcare Provider Details

I. General information

NPI: 1508277963
Provider Name (Legal Business Name): GRADY PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 LEAR INDUSTRIAL PKWY 1A
AVON OH
44011-1379
US

IV. Provider business mailing address

20800 WESTGATE MALL 401
FAIRVIEW PARK OH
44126-1323
US

V. Phone/Fax

Practice location:
  • Phone: 440-937-5400
  • Fax: 440-937-5533
Mailing address:
  • Phone: 440-333-7722
  • Fax: 440-356-0310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36003597
License Number StateOH

VIII. Authorized Official

Name: JACK R GRADY
Title or Position: DPM
Credential: DPM
Phone: 440-937-5400