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General NPI Number Information
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NPI Number | 1831259795
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Entity Type | Organization
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Legal Business Name | GRAND STREET GASTROENTEROLOGY, INC.
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Dates
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Enumeration Date | 12/11/2006
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Last Update Date | 05/20/2021
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Provider Practice Location Address
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Address Line | 33 GRAND ST
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City | KINGSTON
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State | NY
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Zip | 12401-3933
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Country | US
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Telephone | 845-853-8106
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Fax | 845-853-8093
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Provider Business Mailing Address
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Address Line | 33 GRAND ST
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City | KINGSTON
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State | NY
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Zip | 12401-3933
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Country | US
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Telephone | 845-338-2300
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Fax | 845-338-9711
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Authorized Official
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Title or Position | OFFICE MGR./ADMINISTRATOR
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Name | STEPHANIE CLEARWATER
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Credential |
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Telephone | 845-853-8106
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 5501209R
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License Number State | NY
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