MEDICARE: CLYDE GRADY

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		IL

General Provider Information

NPI Number	:	1851484075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLYDE GRADY

Provider Business Mailing Address
First Line	:	104 S BROAD ST
Second Line	:
City	:	KNOXVILLE
State	:	IL
Zip	:	61448-1339
Country	:	US
Telephone Number	:	309-289-2335
Fax Number	:	309-289-8196

Provider Business Practice Location Address
First Line	:	104 S BROAD ST
Second Line	:
City	:	KNOXVILLE
State	:	IL
Zip	:	61448-1339
Country	:	US
Telephone Number	:	309-289-2335
Fax Number	:	309-289-8196

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/08/2007

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Directions to “ CLYDE GRADY ” Practice Location

Language	Start Address	Practice Location

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