Provider Demographics
NPI:1871855270
Name:GROYSMAN, PAVEL (DO)
Entity Type:Individual
Prefix:DR
First Name:PAVEL
Middle Name:
Last Name:GROYSMAN
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 1:17660 UNION TPKE STE 360
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1531
Mailing Address - Country:US
Mailing Address - Phone:718-342-3442
Mailing Address - Fax:347-225-9930
Practice Address - Street 1:17660 UNION TPKE STE 360
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1531
Practice Address - Country:US
Practice Address - Phone:718-342-3442
Practice Address - Fax:347-225-9930
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270491207RG0300X, 207RH0002X
NY270491-1207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04109615Medicaid