1780624023 NPI number — ANTONIO M GRANDA M.D.

Table of content: ANTONIO M GRANDA M.D. (NPI 1780624023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780624023 NPI number — ANTONIO M GRANDA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANDA
Provider First Name:
ANTONIO
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780624023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 468
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SKOWHEGAN
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04976-0468
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-858-8353
Provider Business Mailing Address Fax Number:
207-474-9261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46 FAIRVIEW AVE STE 221
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SKOWHEGAN
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04976-1481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-474-6945
Provider Business Practice Location Address Fax Number:
207-474-6933
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  09565 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 35.143494 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 9565 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: MD23009 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3164315 . This is a "BLUE CROSS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 64746449 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104697 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 378643 . This is a "USA - MCO" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: Q006396 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10074063 . This is a "AMERIGROUP TNCARE AND AMERIVANTAGE MCR ADVANTAGE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1416751 . This is a "CIGNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1507235 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1629728 . This is a "COVENTRY/FIRST HEALTH" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4066743 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1100315241 . This is a "USA PPO/GEHA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 12079645 . This is a "MULTIPLAN/PHCS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 100014907 . This is a "MEDICARE RR" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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