Healthcare Provider Details

I. General information

NPI: 1891352746
Provider Name (Legal Business Name): GARY PRUSKY GRINBERG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GARY PRUSKY DO

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1446 HARPER ST
AUGUSTA GA
30912-0012
US

IV. Provider business mailing address

3301 HART WAY
SNELLVILLE GA
30039-4688
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-9442
  • Fax:
Mailing address:
  • Phone: 678-651-9425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10974
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number92304
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: