Provider Demographics
NPI:1255446191
Name:GRYNWALD, JEFFREY KIRK JR (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:KIRK
Last Name:GRYNWALD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 FAIR PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1720
Mailing Address - Country:US
Mailing Address - Phone:501-604-6900
Mailing Address - Fax:501-604-6941
Practice Address - Street 1:800 FAIR PARK BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204
Practice Address - Country:US
Practice Address - Phone:501-604-6900
Practice Address - Fax:501-604-6941
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY412542086S0105X
ARE-82702086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR201742001Medicaid
ARE-8270OtherARKANSAS MEDICAL LICENSE
AR201742001Medicaid
KY50027698OtherPASSPORT - LAH
ARE-8270OtherARKANSAS MEDICAL LICENSE
AR325345YNV5Medicare PIN
KY109960OtherSIHO - LAH
KY50027698OtherPASSPORT ADVANTAGE - LAH
KY00533204Medicare PIN
KY7100097920Medicaid