Healthcare Provider Details

I. General information

NPI: 1558351668
Provider Name (Legal Business Name): MICHAEL J GRAVELEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 03/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 YORK RD STE 108
JENKINTOWN PA
19046-2852
US

IV. Provider business mailing address

500 YORK RD STE 108
JENKINTOWN PA
19046-2852
US

V. Phone/Fax

Practice location:
  • Phone: 215-481-2725
  • Fax: 215-481-3013
Mailing address:
  • Phone: 215-481-2725
  • Fax: 215-481-3013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-421514
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD-421514
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: