Provider Demographics
NPI:1093957060
Name:GRANDE, CHARLES H (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:H
Last Name:GRANDE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 CARRIE WAY
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-1045
Mailing Address - Country:US
Mailing Address - Phone:724-458-5976
Mailing Address - Fax:
Practice Address - Street 1:1440 CARRIE WAY
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-1045
Practice Address - Country:US
Practice Address - Phone:724-458-5976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003414L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine