MEDICARE: DR. GRIGORIY GRENADER D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	255778	NY

General Provider Information

NPI Number	:	1104085679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRIGORIY GRENADER D.O.

Provider Business Mailing Address
First Line	:	2785 W 5TH ST
Second Line	:	APT.7D
City	:	BROOKLYN
State	:	NY
Zip	:	11224-4629
Country	:	US
Telephone Number	:	646-346-0887
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 HAVEN AVE STE 201
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10032-2645
Country	:	US
Telephone Number	:	212-305-3400
Fax Number	:	212-342-3955

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	03/19/2025

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