1558741124 NPI number — DR. ILYA GRINBERG M.D

Table of content: DR. ILYA GRINBERG M.D (NPI 1558741124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558741124 NPI number — DR. ILYA GRINBERG M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRINBERG
Provider First Name:
ILYA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

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:
1558741124
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3747 60TH ST
Provider Second Line Business Mailing Address:
APARTMENT 1A
Provider Business Mailing Address City Name:
WOODSIDE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11377-2585
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-685-7374
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3747 60TH ST
Provider Second Line Business Practice Location Address:
APARTMENT 1A
Provider Business Practice Location Address City Name:
WOODSIDE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11377-2585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-685-7374
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/08/2015

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: 207L00000X , with the licence number:  298088 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: ME148804 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ME148804 . This is a "STATE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 112196300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com