Basic Information
| Provider Information | |||||||||
| NPI: | 1699282384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRADER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | SAMUEL | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10753 FALLS RD STE 235 | ||||||||
| Address2: | |||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210934597 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 4108473838 | ||||||||
| Practice Location | |||||||||
| Address1: | 1132 ANNAPOLIS RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | ODENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211131672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108741700 | ||||||||
| FaxNumber: | 4108741707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2018 | ||||||||
| LastUpdateDate: | 01/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A4749 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.