Provider Demographics
NPI:1790751485
Name:GRUBB, RONALD G (DO)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:G
Last Name:GRUBB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 S. GULPH RD
Mailing Address - Street 2:ATT: IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:775-356-9393
Mailing Address - Fax:775-356-5590
Practice Address - Street 1:5225 MANATEE AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-3742
Practice Address - Country:US
Practice Address - Phone:941-708-8081
Practice Address - Fax:941-708-8085
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009062L207Q00000X
FLOS11400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00991337OtherRAIL ROAD MEDICARE
PA0016498400007Medicaid
FL003903900Medicaid
FL14F97OtherBCBS
PAP001042OtherGATEWAY
FLFH328ZMedicare PIN
PAG61626Medicare UPIN
PA950605Medicare ID - Type Unspecified