MEDICARE: ROGER DEAN GRIDER M.D.

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	2085R0202X	Diagnostic Radiology Physician	19015	KY
2	2085B0100X	Body Imaging Physician	19015	KY
3	2085U0001X	Diagnostic Ultrasound Physician	19015	KY
4	2085N0904X	Nuclear Radiology Physician	19015	KY

Other Identifiers

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

General Provider Information

NPI Number	:	1538192364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER DEAN GRIDER M.D.

Provider Business Mailing Address
First Line	:	120 E ADAMS ST
Second Line	:	STE 4
City	:	LAGRANGE
State	:	KY
Zip	:	40031-1278
Country	:	US
Telephone Number	:	502-222-3281
Fax Number	:	502-225-5796

Provider Business Practice Location Address
First Line	:	120 E ADAMS ST
Second Line	:	STE 4
City	:	LAGRANGE
State	:	KY
Zip	:	40031-1278
Country	:	US
Telephone Number	:	502-222-3281
Fax Number	:	502-225-5796

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

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	11/09/2007

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Directions to “ ROGER DEAN GRIDER M.D.” Practice Location

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