Basic Information
| Provider Information | |||||||||
| NPI: | 1841236130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANDGEORGE | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | ROY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HITCHCOCK WAY | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031044125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036952500 | ||||||||
| FaxNumber: | 6036952562 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HITCHCOCK WAY | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031044125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036952500 | ||||||||
| FaxNumber: | 6036952562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 09/15/2011 | ||||||||
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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 | 207KA0200X | 6661 | NH | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy | 2080P0214X | 6661 | NH | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 30001628 | 05 | NH | MEDICAID |