Provider Demographics
NPI:1215986773
Name:GRUSH, KENNETH P (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:P
Last Name:GRUSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 MONTAGUE STREET
Mailing Address - Street 2:APT 8A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-3358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:57 MONTAGUE STREET
Practice Address - Street 2:APT 8A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3358
Practice Address - Country:US
Practice Address - Phone:917-882-3587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05061300207L00000X
NY156424 1207L00000X
LAMD 014741207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology