Provider Demographics
NPI:1578565610
Name:GRACE, WILLIAM RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RUSSELL
Last Name:GRACE
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 1:36 7TH AVE
Mailing Address - Street 2:STE 511
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-6600
Mailing Address - Country:US
Mailing Address - Phone:212-675-6826
Mailing Address - Fax:212-366-1697
Practice Address - Street 1:945 FIFTH AVENUE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-2661
Practice Address - Country:US
Practice Address - Phone:212-675-6826
Practice Address - Fax:212-366-1697
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108472174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY311391OtherMEDICARE PROVIDER ID
NY133086258OtherTAX ID #
NYNS3327OtherOXFORD ID
NY1578565610OtherNPI
NYC08231Medicare UPIN
NY311391OtherMEDICARE PROVIDER ID