Basic Information
| Provider Information | |||||||||
| NPI: | 1487093969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRINAGE | ||||||||
| FirstName: | EGBERT | ||||||||
| MiddleName: | FITZSTEPHEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1680 DIAGONAL ROAD | ||||||||
| Address2: | SANFORD WORTHINGTON CLINIC | ||||||||
| City: | WORTHINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073723800 | ||||||||
| FaxNumber: | 5073723806 | ||||||||
| Practice Location | |||||||||
| Address1: | 1680 DIAGONAL RD | ||||||||
| Address2: | SANFORD WORTHINGTON CLINIC | ||||||||
| City: | WORTHINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561871008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073723800 | ||||||||
| FaxNumber: | 5073723806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2013 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 61589 | MN | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | MD192028 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.