Healthcare Provider Details

I. General information

NPI: 1477965820
Provider Name (Legal Business Name): SEAN DEGRANDE M.D, PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-578-5880
  • Fax: 859-578-5881
Mailing address:
  • Phone: 859-578-8550
  • Fax: 859-578-8551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number53667
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number53667
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: