Basic Information
| Provider Information | |||||||||
| NPI: | 1376649483 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRENVILLE MACHADO M.D.,INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2839 COPLEY RD | ||||||||
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| City: | COPLEY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443212154 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2839 COPLEY RD | ||||||||
| Address2: | |||||||||
| City: | COPLEY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443212154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306662022 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
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| AuthorizedOfficialLastName: | MACHADO | ||||||||
| AuthorizedOfficialFirstName: | GRENVILLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3306662022 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2718581 | 05 | OH | MEDICAID |