Provider Demographics
NPI:1477858405
Name:JENNIFER GRODBERG MD, PLLC
Entity type:Organization
Organization Name:JENNIFER GRODBERG MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:GRODBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-360-5379
Mailing Address - Street 1:68 JAY ST
Mailing Address - Street 2:SUITE 507
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1186
Mailing Address - Country:US
Mailing Address - Phone:718-360-5379
Mailing Address - Fax:
Practice Address - Street 1:68 JAY ST
Practice Address - Street 2:SUITE 507
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-1186
Practice Address - Country:US
Practice Address - Phone:718-360-5379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-23
Last Update Date:2011-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219831207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty