Healthcare Provider Details

I. General information

NPI: 1285456863
Provider Name (Legal Business Name): RICHARD THOMAS GRUNKE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2024
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 GLEN COVE DR
ROCKPORT ME
04856-4272
US

IV. Provider business mailing address

6 GLEN COVE DR
ROCKPORT ME
04856-4272
US

V. Phone/Fax

Practice location:
  • Phone: 207-921-8400
  • Fax: 207-921-5280
Mailing address:
  • Phone: 207-921-8400
  • Fax: 207-921-5280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA263045
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1103923
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: