MEDICARE: DR. BERNARD GRUNSTRA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD21854	TN
2	208000000X	Pediatrics Physician	MD21854	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	103I119101	OTHER	TN	MEDICARE PTAN BRMC
3	110162828	OTHER	TN	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	242839	OTHER	VA	ANTHEM PROVIDER NUMBER
5	3076812	OTHER	TN	BLUE CROSS TN PROVIDER #

General Provider Information

NPI Number	:	1558367417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BERNARD GRUNSTRA MD

Provider Business Mailing Address
First Line	:	350 STEELES RD
Second Line	:
City	:	BRISTOL
State	:	TN
Zip	:	37620-9532
Country	:	US
Telephone Number	:	423-844-6700
Fax Number	:	423-844-6703

Provider Business Practice Location Address
First Line	:	350 STEELES RD
Second Line	:
City	:	BRISTOL
State	:	TN
Zip	:	37620-9532
Country	:	US
Telephone Number	:	423-844-6700
Fax Number	:	423-844-6703

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	04/02/2014

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Directions to “ DR. BERNARD GRUNSTRA MD” Practice Location

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