=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174567754
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK EDWIN GRENKOSKI M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2006
-----------------------------------------------------
Last Update Date | 08/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 TALLULAH RD
-----------------------------------------------------
City | ROBBINSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28771-8500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-479-6434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 JOHNSTON FARM LN
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30188-2670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-804-0970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 34687
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 34687
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 38069
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------