MEDICARE: GRADY ERNST

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	208100000X	Physical Medicine & Rehabilitation Physician	28767	FL

General Provider Information

NPI Number	:	1124724588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRADY ERNST

Provider Business Mailing Address
First Line	:	2542 SE WELSH ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34984-5240
Country	:	US
Telephone Number	:	484-571-4111
Fax Number	:

Provider Business Practice Location Address
First Line	:	2542 SE WELSH ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34984-5240
Country	:	US
Telephone Number	:	484-571-4111
Fax Number	:

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

Provider Enumeration Date	:	02/06/2023
Last Update Date	:	02/06/2023

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Directions to “ GRADY ERNST ” Practice Location

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