Healthcare Provider Details

I. General information

NPI: 1265966550
Provider Name (Legal Business Name): ANTHONY JOHN GRANDELIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5141 BROADWAY RM 1RW-097
NEW YORK NY
10034-1159
US

IV. Provider business mailing address

PO BOX 110429
AURORA CO
80042-0429
US

V. Phone/Fax

Practice location:
  • Phone: 212-932-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDR.0065863
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberDR.0065863
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number315323
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: