Provider Demographics
NPI:1790786457
Name:GRAB, EDMUNDO MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:EDMUNDO
Middle Name:MANUEL
Last Name:GRAB
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 1:1701 12TH AVE
Mailing Address - Street 2:BUILDING A
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-3100
Mailing Address - Country:US
Mailing Address - Phone:814-944-7097
Mailing Address - Fax:814-944-5557
Practice Address - Street 1:1701 12TH AVE
Practice Address - Street 2:BUILDING A
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-3100
Practice Address - Country:US
Practice Address - Phone:814-944-7097
Practice Address - Fax:814-944-5557
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD016323E173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006902800003Medicaid
PA164229R9FMedicare ID - Type Unspecified
PA0006902800003Medicaid