Provider Demographics
NPI:1275692675
Name:DAVID P GRUNDMAN DPM
Entity Type:Organization
Organization Name:DAVID P GRUNDMAN DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRUNDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-882-3312
Mailing Address - Street 1:902 N 7TH STREET
Mailing Address - Street 2:PO BOX 404
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591
Mailing Address - Country:US
Mailing Address - Phone:812-882-3312
Mailing Address - Fax:812-882-6181
Practice Address - Street 1:902 N 7TH STREET
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591
Practice Address - Country:US
Practice Address - Phone:812-882-3312
Practice Address - Fax:812-882-6181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000497213E00000X
IL016003243213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200318820AMedicaid
IN0936130001Medicare NSC
IN200318820AMedicaid