Healthcare Provider Details

I. General information

NPI: 1396905212
Provider Name (Legal Business Name): RAISA GRINGAUZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4330 CEDAR LAKE RD S
ST LOUIS PARK MN
55416-3700
US

IV. Provider business mailing address

4725 MINNESOTA LN N
PLYMOUTH MN
55446-2181
US

V. Phone/Fax

Practice location:
  • Phone: 952-381-3434
  • Fax: 952-377-1430
Mailing address:
  • Phone: 952-381-3434
  • Fax: 952-377-1430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number44183
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: