1932130507 NPI number — JOHNATHAN K GRANDY PA

Table of content: JOHNATHAN K GRANDY PA (NPI 1932130507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932130507 NPI number — JOHNATHAN K GRANDY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANDY
Provider First Name:
JOHNATHAN
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRANDY
Provider Other First Name:
JOHN
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1932130507
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 CORPORATE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-3870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-893-9698
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 MEDICAL CENTER PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-877-3400
Provider Business Practice Location Address Fax Number:
207-877-3401
Provider Enumeration Date:
07/05/2006

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: 363A00000X , with the licence number:  010477 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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