Provider Demographics
NPI:1104003235
Name:EDITH GRANNUM MD PC
Entity Type:Organization
Organization Name:EDITH GRANNUM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:GWENDOLINE
Authorized Official - Last Name:GRANNUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-233-1366
Mailing Address - Street 1:PO BOX 18545
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-8545
Mailing Address - Country:US
Mailing Address - Phone:585-233-1366
Mailing Address - Fax:
Practice Address - Street 1:1815 S CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-5720
Practice Address - Country:US
Practice Address - Phone:585-233-1366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210929207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty