Provider Demographics
NPI:1174567754
Name:GRENKOSKI, MARK EDWIN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWIN
Last Name:GRENKOSKI
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 1:215 JOHNSTON FARM LN
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-2670
Mailing Address - Country:US
Mailing Address - Phone:865-804-0970
Mailing Address - Fax:
Practice Address - Street 1:409 TALLULAH RD
Practice Address - Street 2:
Practice Address - City:ROBBINSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28771-8500
Practice Address - Country:US
Practice Address - Phone:828-479-6434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34687207P00000X, 207Q00000X
NC38069207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3860884Medicaid
TN3159891OtherBLUE CROSS
TN3860883Medicaid
TN3159896OtherBLUE CROSS
TNP00206648OtherRAILROAD MEDICARE
TN3860884Medicare PIN
TN3860883Medicare PIN