Healthcare Provider Details

I. General information

NPI: 1346230380
Provider Name (Legal Business Name): FRED E GRUNDEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 8 BOX 665
JASPER TX
75951-9498
US

IV. Provider business mailing address

RR 8 BOX 665
JASPER TX
75951-9498
US

V. Phone/Fax

Practice location:
  • Phone: 409-384-6544
  • Fax:
Mailing address:
  • Phone: 409-384-6544
  • Fax: 409-384-9359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number234517
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: