Basic Information
| Provider Information | |||||||||
| NPI: | 1780624023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANDA | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 468 | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049760468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078588353 | ||||||||
| FaxNumber: | 2074749261 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 FAIRVIEW AVE STE 221 | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049761481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074746945 | ||||||||
| FaxNumber: | 2074746933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 11/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 09565 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 35.143494 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 9565 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | MD23009 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 3164315 | 01 | TN | BLUE CROSS OF TN | OTHER | 64746449 | 05 | KY | MEDICAID | 104697 | 01 | TN | UNITED HEALTH CARE | OTHER | 378643 | 01 | TN | USA - MCO | OTHER | Q006396 | 05 | TN | MEDICAID | 10074063 | 01 | TN | AMERIGROUP TNCARE AND AMERIVANTAGE MCR ADVANTAGE | OTHER | 1416751 | 01 | TN | CIGNA | OTHER | 1507235 | 05 | TN | MEDICAID | 1629728 | 01 | TN | COVENTRY/FIRST HEALTH | OTHER | 4066743 | 01 | TN | AETNA | OTHER | 1100315241 | 01 | TN | USA PPO/GEHA | OTHER | 12079645 | 01 | TN | MULTIPLAN/PHCS | OTHER | 100014907 | 01 | TN | MEDICARE RR | OTHER |