Healthcare Provider Details

I. General information

NPI: 1487093969
Provider Name (Legal Business Name): EGBERT FITZSTEPHEN GRINAGE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MAIN STREET INNERCARE -BRAWLEY
BRAWLEY CA
92227
US

IV. Provider business mailing address

900 MAIN STREET INNERCARE
BRAWLEY CA
92227
US

V. Phone/Fax

Practice location:
  • Phone: 760-344-6741
  • Fax: 760-344-6128
Mailing address:
  • Phone: 760-344-6741
  • Fax: 760-344-6128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberA52876
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA52876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: