Healthcare Provider Details

I. General information

NPI: 1932105780
Provider Name (Legal Business Name): NICHOLAS M GRUMBACH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BALD HILL RD SUITE 520
WARWICK RI
02886-1617
US

IV. Provider business mailing address

400 BALD HILL RD SUITE 520
WARWICK RI
02886-1617
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-8520
  • Fax: 401-793-8527
Mailing address:
  • Phone: 401-793-8520
  • Fax: 401-793-8527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD10410
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD10410
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: