Provider Demographics
NPI:1548668452
Name:GRADY ENDOCRINOLOGY CENTER LLC
Entity type:Organization
Organization Name:GRADY ENDOCRINOLOGY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:GRADY
Authorized Official - Last Name:MATRISCIANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-380-1490
Mailing Address - Street 1:10512 S GLENSTONE PL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-2966
Mailing Address - Country:US
Mailing Address - Phone:225-505-5532
Mailing Address - Fax:225-926-9674
Practice Address - Street 1:10512 S GLENSTONE PL
Practice Address - Street 2:SUITE 102
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-2966
Practice Address - Country:US
Practice Address - Phone:225-505-5532
Practice Address - Fax:225-926-9674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD202783207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty