Healthcare Provider Details

I. General information

NPI: 1861414831
Provider Name (Legal Business Name): REGINA A. GRUBER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 PULASKI HWY
GOSHEN NY
10924-6034
US

IV. Provider business mailing address

1037 MAIN ST CREDENTIALING
PEEKSKILL NY
10566-2913
US

V. Phone/Fax

Practice location:
  • Phone: 845-651-2298
  • Fax: 845-651-2299
Mailing address:
  • Phone: 914-734-8858
  • Fax: 914-734-8786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number220741
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: