Provider Demographics
NPI:1558408740
Name:GRIGORIEFF, NICHOLAS P
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:P
Last Name:GRIGORIEFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 MAIN ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-3313
Mailing Address - Country:US
Mailing Address - Phone:978-371-1684
Mailing Address - Fax:978-371-7504
Practice Address - Street 1:801 MAIN ST
Practice Address - Street 2:SUITE 8
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-3313
Practice Address - Country:US
Practice Address - Phone:978-371-1684
Practice Address - Fax:978-371-7504
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NOT APPLICABLE1744P3200X
225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30003020Medicaid
MA96949701OtherNETWORK HEALTH
MA1531484Medicaid
MA700626OtherHARVARD PILGRIM