Provider Demographics
NPI:1649239054
Name:GRUNDY, LAURENCE SHANE (MD)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:SHANE
Last Name:GRUNDY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 UNIVERSITY SQUARE DRIVE
Mailing Address - Street 2:RADIOLOGY ASSOCIATES OF TAMPA
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-5513
Mailing Address - Country:US
Mailing Address - Phone:813-251-5822
Mailing Address - Fax:813-254-4597
Practice Address - Street 1:2330 UTAH AVE STE 200
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4817
Practice Address - Country:US
Practice Address - Phone:281-766-0959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME719622085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL118774Medicaid
FL261385900Medicaid
FL300125448Medicare PIN
FLE5248SMedicare PIN
FL300093746Medicare PIN
FLE5248UMedicare PIN
FLE5248VMedicare PIN
FLH35577Medicare UPIN
FL300021274Medicare PIN
FL300065508Medicare PIN
FL300024404Medicare PIN
FL261385900Medicaid
FLP00942444Medicare PIN
FLE5248ZMedicare PIN