Healthcare Provider Details

I. General information

NPI: 1598745085
Provider Name (Legal Business Name): RUSSELL GRIESBACK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 E LAUREL RD UDP 3100
STRATFORD NJ
08084-1354
US

IV. Provider business mailing address

42 E LAUREL RD UDP 3100
STRATFORD NJ
08084-1354
US

V. Phone/Fax

Practice location:
  • Phone: 856-566-6859
  • Fax: 856-566-6952
Mailing address:
  • Phone: 856-566-6859
  • Fax: 856-566-6952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMB02248100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMB02248100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: