Provider Demographics
NPI:1558367417
Name:GRUNSTRA, BERNARD (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:
Last Name:GRUNSTRA
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 1:350 STEELES RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-9532
Mailing Address - Country:US
Mailing Address - Phone:423-844-6700
Mailing Address - Fax:423-844-6703
Practice Address - Street 1:350 STEELES RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-9532
Practice Address - Country:US
Practice Address - Phone:423-844-6700
Practice Address - Fax:423-844-6703
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD21854207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006747531Medicaid
TN103I119101OtherMEDICARE PTAN BRMC
TN110162828OtherMEDICARE RAILROAD
VA242839OtherANTHEM PROVIDER NUMBER
TN3076812OtherBLUE CROSS TN PROVIDER #
TN3076812OtherBLUE CROSS TN PROVIDER #
TND92879Medicare UPIN