Basic Information
| Provider Information | |||||||||
| NPI: | 1659365344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRINBLATT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7200 MENTOR AVE | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440607522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409425400 | ||||||||
| FaxNumber: | 4409429055 | ||||||||
| Practice Location | |||||||||
| Address1: | 7200 MENTOR AVE | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440607522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409425400 | ||||||||
| FaxNumber: | 4409429055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 10/26/2012 | ||||||||
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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 | 207RI0011X | 35052369G | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 060054866 | 01 | OH | RAILROAD MEDICARE | OTHER | 0703117 | 05 | OH | MEDICAID |