Basic Information
| Provider Information | |||||||||
| NPI: | 1366762197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRUBBS | ||||||||
| FirstName: | DEANNA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 LANGDON ST | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425032786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066788155 | ||||||||
| FaxNumber: | 6066787548 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 LANGDON ST | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425032786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066788155 | ||||||||
| FaxNumber: | 6066787548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2010 | ||||||||
| LastUpdateDate: | 06/03/2014 | ||||||||
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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 | 208000000X | LL32744 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 46057 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100253060 | 05 | KY | MEDICAID |