MEDICARE: CHARLES FREDERICK GRANNUM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics	040024	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	040024	OTHER	NY	LICENSE

General Provider Information

NPI Number	:	1205904208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES FREDERICK GRANNUM MD

Provider Business Mailing Address
First Line	:	PO BOX 29889
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10087-9889
Country	:	US
Telephone Number	:	800-376-5566
Fax Number	:

Provider Business Practice Location Address
First Line	:	1536 BEDFORD AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-4117
Country	:	US
Telephone Number	:	800-376-5566
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	07/08/2007

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