Provider Demographics
NPI:1437138765
Name:GRUENEICH, ROYAL GENE (PHD)
Entity Type:Individual
Prefix:
First Name:ROYAL
Middle Name:GENE
Last Name:GRUENEICH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 STATE STREET
Mailing Address - Street 2:STE 2A
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5440
Mailing Address - Country:US
Mailing Address - Phone:207-990-2580
Mailing Address - Fax:207-990-1930
Practice Address - Street 1:277 STATE STREET
Practice Address - Street 2:STE 2A
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5440
Practice Address - Country:US
Practice Address - Phone:207-990-2580
Practice Address - Fax:207-990-1930
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS993103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
037935OtherANTHEM
2336158OtherAETNA
037935OtherANTHEM
2336158OtherAETNA