Healthcare Provider Details

I. General information

NPI: 1447286000
Provider Name (Legal Business Name): STACY STEIN GRYBOSKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 EXECUTIVE PARK SOUTH NE 4TH FLOOR - RADIOLOGY IMAGING
ATLANTA GA
30329-2208
US

IV. Provider business mailing address

1161 OAKDALE RD NE
ATLANTA GA
30307-1284
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-5834
  • Fax: 404-778-7015
Mailing address:
  • Phone: 404-370-1551
  • Fax: 404-370-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number40798
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: