Provider Demographics
NPI:1124000369
Name:GRYNYSHIN, IVAN M (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:M
Last Name:GRYNYSHIN
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:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18501-0390
Mailing Address - Country:US
Mailing Address - Phone:570-346-7797
Mailing Address - Fax:570-342-9802
Practice Address - Street 1:420 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3625
Practice Address - Country:US
Practice Address - Phone:570-346-7797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD423998207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010799200001Medicaid
PAP00199596OtherRR MEDICARE
PAP00159374OtherRR MEDICARE
PAP00159374OtherRR MEDICARE
PAP00199596OtherRR MEDICARE
PA1010799200001Medicaid
PA082828F4AMedicare PIN