Provider Demographics
NPI:1720032238
Name:GRANDIA, RONN A (MD)
Entity Type:Individual
Prefix:
First Name:RONN
Middle Name:A
Last Name:GRANDIA
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:PO BOX B
Mailing Address - Street 2:
Mailing Address - City:FRAZIERS BOTTOM
Mailing Address - State:WV
Mailing Address - Zip Code:25082-0251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12075 JERRYS RUN RD
Practice Address - Street 2:
Practice Address - City:APPLE GROVE
Practice Address - State:WV
Practice Address - Zip Code:25502
Practice Address - Country:US
Practice Address - Phone:304-546-0854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-1980208600000X
WV18530208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH310917085052OtherCARESOURCE MEDICAID
000901380OtherMOUNTAIN STATE BCBS
OH000000181638OtherUNISON MEDICAID
OH0848051OtherMOLINA MEDICAID
OH0848051Medicaid
WV1720032238Medicaid
000000211735OtherANTHEM BCBS
OH000000181638OtherUNISON MEDICAID
WV1720032238Medicaid
OH0848051Medicaid
OH310917085052OtherCARESOURCE MEDICAID
WV0698034Medicare PIN
000000211735OtherANTHEM BCBS
OH0848051Medicaid