MEDICARE: DR. JERZY GRZEBIELUCH MD

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	2084P0800X	Psychiatry Physician	ME82784	FL
2	2084P0804X	Child & Adolescent Psychiatry Physician	ME82784	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	53114	OTHER	FL	SPECIALITY LICENSE
2	13115	OTHER	FL	BCBS OF FLORIDA
3	ME 82784	OTHER	FL	FLORIDA LICENSE

General Provider Information

NPI Number	:	1740397025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERZY GRZEBIELUCH MD

Provider Business Mailing Address
First Line	:	4 2ND ST SE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5502
Country	:	US
Telephone Number	:	850-864-2008
Fax Number	:	850-864-5008

Provider Business Practice Location Address
First Line	:	4 2ND ST SE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5502
Country	:	US
Telephone Number	:	850-864-2008
Fax Number	:	850-864-5008

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

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	03/07/2023

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