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General NPI Number Information
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NPI Number | 1699282384
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Entity Type | Individual
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Provider Name | ROBERT SAMUEL GRADER PTA
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Gender | Male
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Dates
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Enumeration Date | 01/04/2018
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Last Update Date | 01/04/2018
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Provider Practice Location Address
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Address Line | 1132 ANNAPOLIS RD STE 101
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City | ODENTON
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State | MD
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Zip | 21113-1672
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Country | US
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Telephone | 410-874-1700
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Fax | 410-874-1707
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Provider Business Mailing Address
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Address Line | 10753 FALLS RD STE 235
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City | LUTHERVILLE
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State | MD
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Zip | 21093-4597
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Country | US
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Telephone |
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Fax | 410-847-3838
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | A4749
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License Number State | MD
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