Provider Demographics
NPI:1861476608
Name:MACHADO, GRENVILLE JOACHIM (MD)
Entity Type:Individual
Prefix:DR
First Name:GRENVILLE
Middle Name:JOACHIM
Last Name:MACHADO
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 1:2839 COPLEY RD
Mailing Address - Street 2:
Mailing Address - City:COPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44321
Mailing Address - Country:US
Mailing Address - Phone:330-666-2022
Mailing Address - Fax:330-665-9659
Practice Address - Street 1:2839 COPLEY RD
Practice Address - Street 2:
Practice Address - City:COPLEY
Practice Address - State:OH
Practice Address - Zip Code:44321
Practice Address - Country:US
Practice Address - Phone:330-666-2022
Practice Address - Fax:330-665-9659
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2008-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH68838207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000184866OtherANTHEM BLUE SHIELD
OH000000184866OtherUNICARE LIFE AND HEALTH
OH410908OtherWELLCARE OF OHIO INC
OH729267OtherBUCKEYE COMMUNITY HEALTH
OH0186418Medicaid
OH176OtherSUMMACARE
G17114Medicare UPIN
OH0186418Medicaid
OH729267OtherBUCKEYE COMMUNITY HEALTH