Provider Demographics
NPI:1952316614
Name:SHTENDER, GRIGORY (MD, PM&R)
Entity Type:Individual
Prefix:
First Name:GRIGORY
Middle Name:
Last Name:SHTENDER
Suffix:
Gender:M
Credentials:MD, PM&R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 E 13TH ST
Mailing Address - Street 2:APT #2D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-7160
Mailing Address - Country:US
Mailing Address - Phone:718-339-2399
Mailing Address - Fax:
Practice Address - Street 1:2995 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-8387
Practice Address - Country:US
Practice Address - Phone:718-934-2211
Practice Address - Fax:718-934-2225
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218261208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02090619Medicaid
NY02090619Medicaid
NY71Z032Medicare PIN
NYH19428Medicare UPIN
NY71Z033Medicare PIN
NY1154J1Medicare PIN
NY71Z031Medicare PIN