MEDICARE: GRADY MARK MCMAHAN DO

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	207Q00000X	Family Medicine Physician	J6584	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00217687	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	8J1203	OTHER	TX	BCBS OF TEXAS

General Provider Information

NPI Number	:	1205839537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRADY MARK MCMAHAN DO

Provider Business Mailing Address
First Line	:	4101 WESLEY ST
Second Line	:	STE C
City	:	GREENVILLE
State	:	TX
Zip	:	75401-5635
Country	:	US
Telephone Number	:	903-454-8111
Fax Number	:	903-454-1680

Provider Business Practice Location Address
First Line	:	4101 WESLEY ST
Second Line	:	STE C
City	:	GREENVILLE
State	:	TX
Zip	:	75401-5635
Country	:	US
Telephone Number	:	903-454-8111
Fax Number	:	903-454-1680

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

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	07/09/2007

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