Healthcare Provider Details

I. General information

NPI: 1518045293
Provider Name (Legal Business Name): JEREMY GRYDER P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3787 WOODRIDGE BLVD.
FAIRFIELD OH
45014
US

IV. Provider business mailing address

7850 STONEGATE DRIVE
CINCINNATI OH
45255
US

V. Phone/Fax

Practice location:
  • Phone: 513-874-1999
  • Fax: 513-874-1653
Mailing address:
  • Phone: 513-474-4486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 010004
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: