Provider Demographics
NPI:1336101054
Name:GRUNDFAST, KENNETH M (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:GRUNDFAST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 HARRISON AVE
Mailing Address - Street 2:SUITE 4005
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 HARRISON AVE
Practice Address - Street 2:SUITE 4005
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-7934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD6119207Y00000X
MA160725207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110061841AMedicaid
MA110061841AMedicaid
MAHX1110Medicare PIN