=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629086699
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILIP L. GRADY APRN/CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2006
-----------------------------------------------------
Last Update Date | 06/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6000 W HIGHWAY 98
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32512-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-304-3389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4145 CASTLE GATE DR
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32571-7352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-304-3389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN9187026
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | ARPN9187026
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------