Healthcare Provider Details

I. General information

NPI: 1114346566
Provider Name (Legal Business Name): JORDON GUY GRUBE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 NEW SCOTLAND AVE # MC-41
ALBANY NY
12208-3403
US

IV. Provider business mailing address

30 STARBUCK DR UNIT 208
GREEN ISLAND NY
12183-1264
US

V. Phone/Fax

Practice location:
  • Phone: 518-262-5575
  • Fax:
Mailing address:
  • Phone: 484-223-9635
  • Fax:

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 Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number306555
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: