Provider Demographics
NPI:1407887185
Name:GROSVENOR, CAROLYN HEYWARD (MD, MPH)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:HEYWARD
Last Name:GROSVENOR
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 HOLLAND AVE
Mailing Address - Street 2:STRATTON VA MEDICAL CENTER MVAC-PRIMARY CARE
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3410
Mailing Address - Country:US
Mailing Address - Phone:518-626-6560
Mailing Address - Fax:518-626-6563
Practice Address - Street 1:113 HOLLAND AVE
Practice Address - Street 2:STRATTON VA MEDICAL CENTER MVAC-PRIMARY CARE
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3410
Practice Address - Country:US
Practice Address - Phone:518-626-6560
Practice Address - Fax:518-626-6563
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146531207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY19992OtherEBCBS
NY10000815OtherCDPHP
NYR70344Medicare ID - Type Unspecified
NY10000815OtherCDPHP