Provider Demographics
NPI:1164543864
Name:MARK R. GRUBB, MD, INC.
Entity Type:Organization
Organization Name:MARK R. GRUBB, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRUBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-966-9328
Mailing Address - Street 1:4774 MUNSON ST NW
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4774 MUNSON ST NW
Practice Address - Street 2:SUITE 302
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3634
Practice Address - Country:US
Practice Address - Phone:330-966-9328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9339081Medicare ID - Type Unspecified