Basic Information
| Provider Information | |||||||||
| NPI: | 1699887810 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUNGPALAN-GRONDOLSKY | ||||||||
| FirstName: | LORI-ANNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 272 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456019031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407797540 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 272 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456019031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407797540 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35084620 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 14755 | HI | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 44120 | MN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2515362 | 05 | OH | MEDICAID | P00180905 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000344370 | 01 | OH | ANTHEM | OTHER |