Provider Demographics
NPI:1144398868
Name:GRANDISON, KATHLEEN L (MD)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:L
Last Name:GRANDISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 CHESTNUT ST FL 2
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-3563
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:325B KING ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2370
Practice Address - Country:US
Practice Address - Phone:413-625-9717
Practice Address - Fax:413-625-9329
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3019799Medicaid
A66432Medicare UPIN
MA3019799Medicaid