Healthcare Provider Details

I. General information

NPI: 1720416191
Provider Name (Legal Business Name): MICHAEL PATRICK GRACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2013
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 SHADOW LAKE RD
WATERFORD VT
05819-9530
US

IV. Provider business mailing address

1220 SHADOW LAKE RD
WATERFORD VT
05819-9530
US

V. Phone/Fax

Practice location:
  • Phone: 802-751-7675
  • Fax:
Mailing address:
  • Phone: 802-751-7675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number042.0007602
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: