Provider Demographics
NPI:1225036551
Name:GRADY, WALTER (DO)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:GRADY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:480 FLOYD RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1518
Practice Address - Country:US
Practice Address - Phone:864-582-2115
Practice Address - Fax:864-582-2117
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC504207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC005041Medicaid
SCP01045397OtherRAILROAD MEDICARE
SCQ699617628Medicare PIN
SCG69961Medicare UPIN
SC5424450001Medicare NSC