Provider Demographics
NPI:1598745085
Name:GRIESBACK, RUSSELL (DO)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:
Last Name:GRIESBACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 E LAUREL RD
Mailing Address - Street 2:UDP 3100
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1354
Mailing Address - Country:US
Mailing Address - Phone:856-566-6859
Mailing Address - Fax:856-566-6952
Practice Address - Street 1:42 E LAUREL RD
Practice Address - Street 2:UDP 3100
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1354
Practice Address - Country:US
Practice Address - Phone:856-566-6859
Practice Address - Fax:856-566-6952
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB02248100207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1853503Medicaid
NJ1853503Medicaid
NJC52853Medicare UPIN