Healthcare Provider Details

I. General information

NPI: 1912279415
Provider Name (Legal Business Name): ELIZABETH ROSE GRUBB MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2012
Last Update Date: 01/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 BROADWAY MAIL CODE 1915
NEW YORK NY
10027-6907
US

IV. Provider business mailing address

560 RIVERSIDE DR 14M
NEW YORK NY
10027-3202
US

V. Phone/Fax

Practice location:
  • Phone: 212-854-3178
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001959-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: