Provider Demographics
NPI:1053305862
Name:ROBERT B GRZYWACZ DPM A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ROBERT B GRZYWACZ DPM A PROFESSIONAL CORPORATION
Other - Org Name:DESERT PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:GRZYWACZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-733-7617
Mailing Address - Street 1:3221 E WARM SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3157
Mailing Address - Country:US
Mailing Address - Phone:702-733-7617
Mailing Address - Fax:702-733-1732
Practice Address - Street 1:3221 E WARM SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3157
Practice Address - Country:US
Practice Address - Phone:702-733-7617
Practice Address - Fax:702-733-1732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV793965375213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
37963OtherMEDICARE SECONDARY
NVP00058662OtherRAILROAD MEDICARE
37963OtherMEDICARE CLAIMS
V37962OtherGEHA
137141EQOtherPREFERRED CARE
V37963OtherMEDICARE CLAIMS
37963OtherMEDICARE CLAIMS
=========0000EOtherGEHA
=========0000EOtherGEHA
37963OtherMEDICARE SECONDARY
V37963OtherMEDICARE CLAIMS