Provider Demographics
NPI:1124009253
Name:GRENGA, TAD EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:TAD
Middle Name:EDWARD
Last Name:GRENGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5818 HARBOUR VIEW BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3315
Mailing Address - Country:US
Mailing Address - Phone:757-673-5900
Mailing Address - Fax:757-673-5905
Practice Address - Street 1:5818 HARBOUR VIEW BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3315
Practice Address - Country:US
Practice Address - Phone:757-673-5900
Practice Address - Fax:757-673-5905
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041085208200000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006901395Medicaid
VA118152OtherANTHEM
VA410829OtherMAMSI
VA15906OtherSENTARA/OPTIMA
VA006901395Medicaid
VA2400000247Medicare PIN
VA118152OtherANTHEM