Provider Demographics
NPI:1760600266
Name:EAST BAY PEDIATRIC & ADOLESCENT MEDICINE ASSOCIATES INC
Entity Type:Organization
Organization Name:EAST BAY PEDIATRIC & ADOLESCENT MEDICINE ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRENANDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-247-1644
Mailing Address - Street 1:234 MAPLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:RI
Mailing Address - Zip Code:02806
Mailing Address - Country:US
Mailing Address - Phone:401-247-1644
Mailing Address - Fax:401-247-4961
Practice Address - Street 1:234 MAPLE AVENUE
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:RI
Practice Address - Zip Code:02806
Practice Address - Country:US
Practice Address - Phone:401-247-1644
Practice Address - Fax:401-247-4961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty