Provider Demographics
NPI:1013735802
Name:PROMED PREFERRED WI SC
Entity type:Organization
Organization Name:PROMED PREFERRED WI SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEV
Authorized Official - Middle Name:
Authorized Official - Last Name:GRINMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-499-3165
Mailing Address - Street 1:329 S OYSTER BAY RD STE 2059
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-3301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 2ND ST S
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-2234
Practice Address - Country:US
Practice Address - Phone:615-499-3165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty