Provider Demographics
NPI:1316961071
Name:GRENVILLE MEDICAL PC
Entity type:Organization
Organization Name:GRENVILLE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KABAKOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-576-4481
Mailing Address - Street 1:308A E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4001
Mailing Address - Country:US
Mailing Address - Phone:212-674-4455
Mailing Address - Fax:
Practice Address - Street 1:308A E 15TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4001
Practice Address - Country:US
Practice Address - Phone:212-674-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075329207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00100936Medicaid
NYW9D001Medicare ID - Type Unspecified
NY00100936Medicaid