Healthcare Provider Details

I. General information

NPI: 1861476608
Provider Name (Legal Business Name): GRENVILLE JOACHIM MACHADO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 05/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2839 COPLEY RD
COPLEY OH
44321
US

IV. Provider business mailing address

2839 COPLEY RD
COPLEY OH
44321
US

V. Phone/Fax

Practice location:
  • Phone: 330-666-2022
  • Fax: 330-665-9659
Mailing address:
  • Phone: 330-666-2022
  • Fax: 330-665-9659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number68838
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: