Basic Information
| Provider Information | |||||||||
| NPI: | 1033184833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAU | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3130 N COUNTY ROAD 25A | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374404466 | ||||||||
| FaxNumber: | 9374407177 | ||||||||
| Practice Location | |||||||||
| Address1: | 3130 N COUNTY ROAD 25A | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374404466 | ||||||||
| FaxNumber: | 9374407177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 11/14/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35.074254 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2212680 | 05 | OH | MEDICAID |