1720032238 NPI number — RONN A. GRANDIA M.D.

Table of content: RONN A. GRANDIA M.D. (NPI 1720032238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720032238 NPI number — RONN A. GRANDIA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANDIA
Provider First Name:
RONN
Provider Middle Name:
A.
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:
1720032238
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRAZIERS BOTTOM
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25082-0251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12075 JERRYS RUN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPLE GROVE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-546-0854
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/20/2006

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: 208600000X , with the licence number:  35-06-1980 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 18530 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 310917085052 . This is a "CARESOURCE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000901380 . This is a "MOUNTAIN STATE BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000181638 . This is a "UNISON MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0848051 . This is a "MOLINA MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0848051 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1720032238 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000211735 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".




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