Provider Demographics
NPI:1427040534
Name:GRUBB, SHANNON L (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:GRUBB
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 1:4201 AERO DR
Mailing Address - Street 2:DOCTORS URGENT CARE
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-8818
Mailing Address - Country:US
Mailing Address - Phone:513-770-4122
Mailing Address - Fax:513-459-9468
Practice Address - Street 1:4201 AERO DR
Practice Address - Street 2:DOCTORS URGENT CARE
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-8818
Practice Address - Country:US
Practice Address - Phone:513-770-4122
Practice Address - Fax:513-459-9468
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057544G207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0728672Medicaid
OHGR4124482OtherMEDICARE PTAN
OH0728672Medicaid