1568485985 NPI number — GRAND STREET MEDICAL PLLC

Table of content: (NPI 1568485985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568485985 NPI number — GRAND STREET MEDICAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND STREET MEDICAL PLLC
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:
JAYANT H. GANDHI,M.D.
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:
1568485985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 E END AVE
Provider Second Line Business Mailing Address:
14-B
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10028-8004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-734-9031
Provider Business Mailing Address Fax Number:
212-794-2441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
666 GRAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11211-4853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-963-0555
Provider Business Practice Location Address Fax Number:
718-963-4889
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GANDHI
Authorized Official First Name:
HEMA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
ADMINISTRATION
Authorized Official Telephone Number:
718-782-4768

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  111281 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 111281 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X , with the licence number: 111281 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RX0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: 111281 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 111281 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 111281 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GJ617239 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0192659 . This is a "GRAND STREET MEDICAL PC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 12295130 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 55247 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00199748 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11128160NY . This is a "1199 NATIONAL BENEFIT" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: WPPD41 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03196274 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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