Healthcare Provider Details

I. General information

NPI: 1396982021
Provider Name (Legal Business Name): SVETLANA GRINBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2009
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E FORDHAM RD
BRONX NY
10458-5049
US

IV. Provider business mailing address

625 E FORDHAM RD
BRONX NY
10458-5049
US

V. Phone/Fax

Practice location:
  • Phone: 718-933-1900
  • Fax: 718-933-5321
Mailing address:
  • Phone: 718-933-1900
  • Fax: 718-933-5321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number008575
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: