Provider Demographics
NPI:1588653687
Name:GRUMBACK, PAUL L (PT LAC)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:L
Last Name:GRUMBACK
Suffix:
Gender:M
Credentials:PT LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 ACRE LN
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-4442
Mailing Address - Country:US
Mailing Address - Phone:516-932-3286
Mailing Address - Fax:516-932-0669
Practice Address - Street 1:167 ACRE LN
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-4442
Practice Address - Country:US
Practice Address - Phone:516-932-3286
Practice Address - Fax:516-932-0669
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0012381171100000X
NY0059051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171100000XOther Service ProvidersAcupuncturist
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2119754OtherVUTRA
NYA497485OtherOXFORD
NY6601380OtherGHI
NY8080257OtherUHC EMPIRE PLAN
NY20137POtherHIP
NYQ81361Medicare ID - Type Unspecified