Individual
IVAN M GRYNYSHIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
420 S JACKSON ST, POTTSVILLE, PA 17901-3625
(570) 346-7797
Mailing address
PO BOX 390, SCRANTON, PA 18501-0390
(570) 346-7797
(570) 342-9802
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
MD423998
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1010799200001
—
PA
01
—
P00159374
RR MEDICARE
PA
01
—
P00199596
RR MEDICARE
PA
Enumeration date
11/15/2005
Last updated
04/20/2009
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