Healthcare Provider Details

I. General information

NPI: 1629033709
Provider Name (Legal Business Name): MIKHAIL GRZHIBEK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 SILLS RD BUILDING 4 SUITE D
EAST PATCHOGUE NY
11772-4869
US

IV. Provider business mailing address

285 SILLS RD BUILDING 4, SUITE D
EAST PATCHOGUE NY
11772-4869
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-1800
  • Fax: 631-240-9181
Mailing address:
  • Phone: 917-750-2937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number239339
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: