Provider Demographics
NPI:1083639520
Name:LEVIN, GRIGORIY (CRNA)
Entity Type:Individual
Prefix:
First Name:GRIGORIY
Middle Name:
Last Name:LEVIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 874
Mailing Address - Street 2:
Mailing Address - City:ELMER
Mailing Address - State:NJ
Mailing Address - Zip Code:08318-0874
Mailing Address - Country:US
Mailing Address - Phone:856-358-4520
Mailing Address - Fax:856-358-8053
Practice Address - Street 1:2301 EVESHAM RD.
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043
Practice Address - Country:US
Practice Address - Phone:856-358-4520
Practice Address - Fax:856-358-8053
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR11030200367500000X
PARN545229367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ084690Medicare ID - Type Unspecified