MEDICARE: DR. IRA GRUSHACK D.C.

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	111NS0005X	Sports Physician Chiropractor	3174	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	321281	OTHER	NY	AETNA

General Provider Information

NPI Number	:	1407896897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IRA GRUSHACK D.C.

Provider Business Mailing Address
First Line	:	714 E PARK AVE
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-2605
Country	:	US
Telephone Number	:	516-431-7972
Fax Number	:	516-431-7944

Provider Business Practice Location Address
First Line	:	714 E PARK AVE
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-2605
Country	:	US
Telephone Number	:	516-431-7972
Fax Number	:	516-431-7944

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

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	07/08/2007

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