Provider Demographics
NPI:1528389871
Name:GRUBE RETINA CLINIC PC
Entity Type:Organization
Organization Name:GRUBE RETINA CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GRUBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-214-7879
Mailing Address - Street 1:107 3RD AVE NW
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3129
Mailing Address - Country:US
Mailing Address - Phone:701-751-2131
Mailing Address - Fax:
Practice Address - Street 1:107 3RD AVE NW
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3129
Practice Address - Country:US
Practice Address - Phone:701-751-2131
Practice Address - Fax:701-751-2133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-21
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9201207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1659328516Medicaid