1013989870 NPI number — SUSAN K GRENZ MD

Table of content: SUSAN K GRENZ MD (NPI 1013989870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013989870 NPI number — SUSAN K GRENZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRENZ
Provider First Name:
SUSAN
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1013989870
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
779 VIA LOS ALTOS UNIT C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA WOODS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92637-4828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-798-6640
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
779 C VIA LOS ALTOS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGUNA WOODS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-798-6640
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  18697 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 12279 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 102600 . This is a "AUMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 123062 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3000067 . This is a "BAYCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 622728 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3386236002 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 123063 . This is a "HUMANA GOLD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 62527 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 592712571 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".




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