Provider Demographics
NPI:1366416604
Name:PARE, GRADY H (MD)
Entity type:Individual
Prefix:
First Name:GRADY
Middle Name:H
Last Name:PARE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9577
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-9577
Mailing Address - Country:US
Mailing Address - Phone:270-745-1467
Mailing Address - Fax:270-745-1156
Practice Address - Street 1:250 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1760
Practice Address - Country:US
Practice Address - Phone:270-745-1626
Practice Address - Fax:270-842-8722
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27288207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64272883Medicaid
F19195Medicare UPIN
KY0557603Medicare ID - Type Unspecified