Provider Demographics
NPI:1821060237
Name:GRANNUM, EDITH (MD)
Entity Type:Individual
Prefix:DR
First Name:EDITH
Middle Name:
Last Name:GRANNUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 CLINTON AVE S STE 330
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-5717
Mailing Address - Country:US
Mailing Address - Phone:585-461-6000
Mailing Address - Fax:585-461-6009
Practice Address - Street 1:1815 CLINTON AVE S STE 330
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-5717
Practice Address - Country:US
Practice Address - Phone:585-461-6004
Practice Address - Fax:585-461-6009
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210929207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01894408Medicaid
NYRB0445Medicare ID - Type Unspecified
NY01894408Medicaid