Healthcare Provider Details

I. General information

NPI: 1780644831
Provider Name (Legal Business Name): CHARLES R GRUBB DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3794 HECKTOWN RD STE 250
EASTON PA
18045-2355
US

IV. Provider business mailing address

311 BALTIMORE ST
PHILLIPSBURG NJ
08865-1841
US

V. Phone/Fax

Practice location:
  • Phone: 484-544-0122
  • Fax:
Mailing address:
  • Phone: 908-454-8787
  • Fax: 908-454-1192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB03357700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS003693L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: