Healthcare Provider Details

I. General information

NPI: 1881358851
Provider Name (Legal Business Name): ANATOLIY OLEXANDROVYCH GRYSHCHENKO IDHS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 10/26/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 COAST GUARD BLVD
PORTSMOUTH VA
23703-2135
US

IV. Provider business mailing address

USCGC TAMPA 4000 COAST GUARD BLVD
APO AA
23703
US

V. Phone/Fax

Practice location:
  • Phone: 757-483-8710
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: