Basic Information
| Provider Information | |||||||||
| NPI: | 1437682267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRUNDT | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | JEFFREY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26606 MAGNOLIA BLVD | ||||||||
| Address2: | |||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335598545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1390701238 | ||||||||
| FaxNumber: | 8139075559 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 14TH ST SW | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337703133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275885704 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2017 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS16891 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | OS16891 | FL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 108480300 | 05 | FL | MEDICAID |