Provider Demographics
NPI:1114004546
Name:CHARLES R GRUBB DO PC
Entity Type:Organization
Organization Name:CHARLES R GRUBB DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUKIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-454-8787
Mailing Address - Street 1:311 BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-1627
Mailing Address - Country:US
Mailing Address - Phone:908-454-8787
Mailing Address - Fax:908-454-1192
Practice Address - Street 1:311 BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865
Practice Address - Country:US
Practice Address - Phone:908-454-8787
Practice Address - Fax:908-454-1192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB033577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02292400OtherCAPITAL BLUE CROSS
PA02292400OtherCAPITAL BLUE CROSS
PA02292400OtherCAPITAL BLUE CROSS
PA063781Medicare PIN
NJ2=========OtherHORIZON BLUE CROSS