Provider Demographics
NPI:1568468700
Name:GRYSKA, PAUL VONRYLL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:VONRYLL
Last Name:GRYSKA
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 1:2000 WASHINGTON ST
Mailing Address - Street 2:STE 365
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1627
Mailing Address - Country:US
Mailing Address - Phone:617-244-5355
Mailing Address - Fax:617-244-8662
Practice Address - Street 1:2000 WASHINGTON ST
Practice Address - Street 2:STE 365
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1627
Practice Address - Country:US
Practice Address - Phone:617-244-5355
Practice Address - Fax:617-244-8662
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52655208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6181112Medicaid
MAA68129Medicare UPIN
MA6181112Medicaid