Healthcare Provider Details

I. General information

NPI: 1518961952
Provider Name (Legal Business Name): CHARLES GRUENWALD JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 BLUEBONNET BLVD
BATON ROUGE LA
70809
US

IV. Provider business mailing address

4309 BLUEBONNET BLVD
BATON ROUGE LA
70809
US

V. Phone/Fax

Practice location:
  • Phone: 225-925-3140
  • Fax: 225-223-6010
Mailing address:
  • Phone: 225-925-3140
  • Fax: 225-223-6010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number04294R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: