Provider Demographics
NPI:1699749176
Name:GRACE, TED (MD)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:GRACE
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 1:1875 MILLIKIN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-2200
Mailing Address - Country:US
Mailing Address - Phone:614-292-0110
Mailing Address - Fax:614-247-6074
Practice Address - Street 1:1875 MILLIKIN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-2200
Practice Address - Country:US
Practice Address - Phone:614-292-0110
Practice Address - Fax:614-247-6074
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-039747171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHA49704Medicare UPIN
OHGR0848781Medicare ID - Type Unspecified