Provider Demographics
NPI:1346297074
Name:BROOKLYN UROLOGY P.C.
Entity Type:Organization
Organization Name:BROOKLYN UROLOGY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUNBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-569-0696
Mailing Address - Street 1:141 COMBS AVE
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1432
Mailing Address - Country:US
Mailing Address - Phone:516-569-0696
Mailing Address - Fax:516-569-3677
Practice Address - Street 1:1 PROSPECT PARK W
Practice Address - Street 2:SUITE C
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-1601
Practice Address - Country:US
Practice Address - Phone:718-230-7788
Practice Address - Fax:718-230-8017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146673208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01794123Medicaid
NYW1L641Medicare PIN