Provider Demographics
NPI:1568485985
Name:GRAND STREET MEDICAL PLLC
Entity Type:Organization
Organization Name:GRAND STREET MEDICAL PLLC
Other - Org Name:JAYANT H. GANDHI,M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEMA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GANDHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-782-4768
Mailing Address - Street 1:80 E END AVE
Mailing Address - Street 2:14-B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-8004
Mailing Address - Country:US
Mailing Address - Phone:212-734-9031
Mailing Address - Fax:212-794-2441
Practice Address - Street 1:666 GRAND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-4853
Practice Address - Country:US
Practice Address - Phone:718-963-0555
Practice Address - Fax:718-963-4889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111281207Q00000X, 207R00000X, 207RG0300X, 208100000X, 208600000X, 208D00000X
207QA0401X, 207QG0300X, 207RX0202X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYGJ617239OtherGHI
NY0192659OtherGRAND STREET MEDICAL PC
12295130OtherCAQH
NY55247OtherHIP
NY00199748Medicaid
NY11128160NYOther1199 NATIONAL BENEFIT
NYWPPD41Medicaid
NY03196274Medicaid
NYGJ617239OtherGHI
NYB78173Medicare UPIN
NYWPPD41Medicaid