Provider Demographics
NPI:1306976428
Name:JACEK GRZYBOWSKI MD LLC
Entity type:Organization
Organization Name:JACEK GRZYBOWSKI MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACEK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRZYBOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-587-9611
Mailing Address - Street 1:812 N WOOD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-4058
Mailing Address - Country:US
Mailing Address - Phone:908-587-9611
Mailing Address - Fax:908-587-9622
Practice Address - Street 1:812 N WOOD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-4058
Practice Address - Country:US
Practice Address - Phone:908-587-9611
Practice Address - Fax:908-587-9622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0059862Medicaid