1689780819 NPI number — DR. ROCCO D GRELLA MD

Table of content: DR. ROCCO D GRELLA MD (NPI 1689780819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689780819 NPI number — DR. ROCCO D GRELLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRELLA
Provider First Name:
ROCCO
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1689780819
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
571 SAINT JOSEPHS BLVD
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
ELMIRA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14901-3230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-271-2050
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 IVY ST
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
ELMIRA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14905-1646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-739-1529
Provider Business Practice Location Address Fax Number:
607-739-1378
Provider Enumeration Date:
08/21/2006

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: 207RC0000X , with the licence number:  1806731 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 180673 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X , with the licence number: MD444814 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 102239429 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01497947 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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