Provider Demographics
NPI:1043298946
Name:GRANDSTAFF, PHILLIP M (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:M
Last Name:GRANDSTAFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:75 STATE ST FL 26
Mailing Address - Street 2:ATTN: EMILY RUNEY
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-1827
Mailing Address - Country:US
Mailing Address - Phone:617-204-3547
Mailing Address - Fax:617-428-4917
Practice Address - Street 1:210 RICHMOND CT
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78552-1935
Practice Address - Country:US
Practice Address - Phone:956-230-0896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS0426890207P00000X
TXP2252207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F77586Medicare UPIN