Healthcare Provider Details

I. General information

NPI: 1669950671
Provider Name (Legal Business Name): JOSEPH M GRZELAK IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6105 1ST FINANCIAL DR
BURLINGTON KY
41005-7892
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-586-8200
  • Fax: 859-586-8233
Mailing address:
  • Phone: 859-586-8200
  • Fax: 859-586-8233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number54914
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: