Provider Demographics
NPI:1043418544
Name:GRUDZEN, CORITA REILLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:CORITA
Middle Name:REILLEY
Last Name:GRUDZEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-3293
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-3293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91053207P00000X
NY233941-1207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
070913000141OtherFIDELISCARE OF NY
6007526OtherMVP HEALTHPLAN PIN #
7243967OtherAETNA PPO #
1591896OtherAETNA HMO PIN #
3592Q1OtherEMPIRE BC BS
0170035OtherGHI PPO PIN #
10127536OtherCDPHP PIN #
6C5394OtherHEALTHNET PIN #
000000120752OtherGHI HMO PIN#
6007526OtherMVP HEALTHPLAN PIN #
1591896OtherAETNA HMO PIN #