Provider Demographics
NPI:1487629614
Name:GRACHEV, SERGEY (MD)
Entity Type:Individual
Prefix:
First Name:SERGEY
Middle Name:
Last Name:GRACHEV
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 367
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-0367
Mailing Address - Country:US
Mailing Address - Phone:609-597-9477
Mailing Address - Fax:609-597-9877
Practice Address - Street 1:115 E BAY AVE
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-3109
Practice Address - Country:US
Practice Address - Phone:609-597-9477
Practice Address - Fax:609-597-9877
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07937200208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI47876Medicare UPIN
NJ097171UXBMedicare ID - Type Unspecified