Provider Demographics
NPI:1699727347
Name:GREBENC, MARY L (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:GREBENC
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:
Practice Address - Street 1:1 UNM
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-3616
Practice Address - Country:US
Practice Address - Phone:505-272-2525
Practice Address - Fax:505-272-6055
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG872332085R0202X
NM90-1992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G872330Medicaid
CA00G872330OtherBLUE SHIELD PIN
CAWG87233AMedicare PIN
CA00G872330OtherBLUE SHIELD PIN
CAE57499Medicare UPIN
CAWG87233BMedicare PIN