Provider Demographics
NPI:1861439937
Name:GRAINGER, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GRAINGER
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 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-431-0090
Mailing Address - Fax:859-431-3168
Practice Address - Street 1:119 FAIRFIELD AVE
Practice Address - Street 2:SUITE R102
Practice Address - City:BELLEVUE
Practice Address - State:KY
Practice Address - Zip Code:41073
Practice Address - Country:US
Practice Address - Phone:859-431-0090
Practice Address - Fax:859-431-3168
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0993064Medicaid
KY64238280Medicaid
KY080092530OtherRAILROAD MEDICARE
KYP00839903OtherRAILROAD MEDICARE
KY080092530OtherRAILROAD MEDICARE
KYC75462Medicare UPIN
KY0387602Medicare PIN