Healthcare Provider Details

I. General information

NPI: 1407233372
Provider Name (Legal Business Name): TORI BROOKE GRENADE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 09/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GROVE RD ATT: RESIDENCY COORDINDATOR
GREENVILLE SC
29605-5611
US

IV. Provider business mailing address

1601 WATSON BLVD
WARNER ROBINS GA
31093-3431
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-7844
  • Fax: 864-455-7848
Mailing address:
  • Phone: 478-922-4281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number83844
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number83844
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: