Provider Demographics
NPI:1891872719
Name:DIANNE M. GREJTAK
Entity Type:Organization
Organization Name:DIANNE M. GREJTAK
Other - Org Name:MEDICAL SPECIALTY SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GREJTAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-614-3360
Mailing Address - Street 1:4944 RESEARCH DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-5006
Mailing Address - Country:US
Mailing Address - Phone:210-614-3360
Mailing Address - Fax:210-614-3362
Practice Address - Street 1:4944 RESEARCH DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-5006
Practice Address - Country:US
Practice Address - Phone:210-614-3360
Practice Address - Fax:210-614-3362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0065742332B00000X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0007451364OtherAETNA TRS
TX531788OtherBCBS FEDERAL
TX155364601Medicaid
TX531788OtherBCBS TX
TX190990121250OtherHUMANA
TX155364602Medicaid
TN4037010OtherBCBS TN
TX585599OtherBCBS KS
TX190990121250OtherHUMANA