Healthcare Provider Details

I. General information

NPI: 1033372578
Provider Name (Legal Business Name): BRANDON CY GRINAGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 09/08/2024
Certification Date: 09/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 POWERS FERRY RD SE STE 120
MARIETTA GA
30067-9401
US

IV. Provider business mailing address

1545 POWERS FERRY RD SE STE 120
MARIETTA GA
30067-9401
US

V. Phone/Fax

Practice location:
  • Phone: 770-580-0979
  • Fax: 678-383-6735
Mailing address:
  • Phone: 770-580-0979
  • Fax: 678-383-6735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number068419
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLL31143
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: