Basic Information
| Provider Information | |||||||||
| NPI: | 1649239054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRUNDY | ||||||||
| FirstName: | LAURENCE | ||||||||
| MiddleName: | SHANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 UNIVERSITY SQUARE DRIVE | ||||||||
| Address2: | RADIOLOGY ASSOCIATES OF TAMPA | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336125513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132515822 | ||||||||
| FaxNumber: | 8132544597 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 UNIVERSITY SQUARE DRIVE | ||||||||
| Address2: | RADIOLOGY ASSOCIATES OF TAMPA | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336125513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132515822 | ||||||||
| FaxNumber: | 8132544597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME71962 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | ME71962 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 261385900 | 05 | FL | MEDICAID | 118774 | 05 | AL | MEDICAID |