MEDICARE: JERZY GRZEBIELUCH, MD, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1447809298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JERZY GRZEBIELUCH, MD, LLC

Provider Business Mailing Address
First Line	:	4 2ND ST SE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5502
Country	:	US
Telephone Number	:	850-864-2008
Fax Number	:	850-864-5008

Provider Business Practice Location Address
First Line	:	4 2ND ST SE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5502
Country	:	US
Telephone Number	:	850-864-2008
Fax Number	:	850-864-5008

Authorized Official
Title or Position	:	OWNER
Name	:	JERZY GRZEBIELUCH
Credential	:	MD
Telephone Number	:	850-864-2008

Provider Enumeration Date	:	09/04/2019
Last Update Date	:	09/04/2019

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