Provider Demographics
NPI:1912909896
Name:GRINBERG, MARC A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:A
Last Name:GRINBERG
Suffix:
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 1:1880 ARLINGTON ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-3505
Mailing Address - Country:US
Mailing Address - Phone:941-366-7611
Mailing Address - Fax:941-957-4761
Practice Address - Street 1:1880 ARLINGTON ST
Practice Address - Street 2:101
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3524
Practice Address - Country:US
Practice Address - Phone:941-366-7611
Practice Address - Fax:941-957-4761
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2008-04-30
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
FLME17033174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0494300001Medicare NSC
FLD50015Medicare UPIN
01195Medicare ID - Type Unspecified