1053305862 NPI number — ROBERT B GRZYWACZ DPM A PROFESSIONAL CORPORATION

Table of content: (NPI 1053305862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053305862 NPI number — ROBERT B GRZYWACZ DPM A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT B GRZYWACZ DPM A PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DESERT PODIATRY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053305862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3221 E WARM SPRINGS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89120-3157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-733-7617
Provider Business Mailing Address Fax Number:
702-733-1732

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3221 E WARM SPRINGS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89120-3157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-733-7617
Provider Business Practice Location Address Fax Number:
702-733-1732
Provider Enumeration Date:
09/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GRZYWACZ
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
702-733-7617

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  793965375 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 37963 . This is a "MEDICARE SECONDARY" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00058662 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 37963 . This is a "MEDICARE CLAIMS" identifier . This identifiers is of the category "OTHER".
  • Identifier: V37962 . This is a "GEHA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 137141EQ . This is a "PREFERRED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: V37963 . This is a "MEDICARE CLAIMS" identifier . This identifiers is of the category "OTHER".




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