Provider Demographics
NPI:1356334601
Name:GRANDI, RENEE E (MD)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:E
Last Name:GRANDI
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 1:603 MEDICAL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-1168
Mailing Address - Country:US
Mailing Address - Phone:541-426-4502
Mailing Address - Fax:541-426-6403
Practice Address - Street 1:603 MEDICAL PARKWAY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-1168
Practice Address - Country:US
Practice Address - Phone:541-426-4502
Practice Address - Fax:541-426-6403
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23645207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5966015OtherBCBS
OR80184662OtherRAILROAD MEDICARE
OKJ054902OtherPACIFIC SOURCE
OR286848Medicaid
OR1103330001Medicare NSC
OKJ054902OtherPACIFIC SOURCE
OR112714Medicare ID - Type Unspecified