Healthcare Provider Details

I. General information

NPI: 1568485985
Provider Name (Legal Business Name): GRAND STREET MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

666 GRAND ST
BROOKLYN NY
11211-4853
US

IV. Provider business mailing address

80 E END AVE 14-B
NEW YORK NY
10028-8004
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-0555
  • Fax: 718-963-4889
Mailing address:
  • Phone: 212-734-9031
  • Fax: 212-794-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number111281
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number111281
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number111281
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number111281
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number111281
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number111281
License Number StateNY

VIII. Authorized Official

Name: MRS. HEMA J GANDHI
Title or Position: ADMINISTRATION
Credential:
Phone: 718-782-4768