Provider Demographics
NPI:1104812247
Name:GRUCELA, RICHARD P (MS PT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:P
Last Name:GRUCELA
Suffix:
Gender:M
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 ROXTON RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-1143
Mailing Address - Country:US
Mailing Address - Phone:516-993-3178
Mailing Address - Fax:516-681-0884
Practice Address - Street 1:800 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5314
Practice Address - Country:US
Practice Address - Phone:516-829-8450
Practice Address - Fax:516-829-8452
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003102225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ53921OtherBCBS
NYQ53921Medicare ID - Type Unspecified