MEDICARE: VICTORIA E GRADY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	95-00597	NC
2	207R00000X	Internal Medicine Physician	0101053568	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	021044C18	OTHER	VA	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043275852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA E GRADY MD

Provider Business Mailing Address
First Line	:	PO BOX 419402
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02241-9402
Country	:	US
Telephone Number	:	855-290-1552
Fax Number	:	336-774-6872

Provider Business Practice Location Address
First Line	:	8051 PROSPERITY WAY STE 100
Second Line	:
City	:	RUTHER GLEN
State	:	VA
Zip	:	22546
Country	:	US
Telephone Number	:	804-448-0198
Fax Number	:	804-448-0598

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2006
Last Update Date	:	08/28/2019

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Directions to “ VICTORIA E GRADY MD” Practice Location

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