Basic Information
| Provider Information | |||||||||
| NPI: | 1033210661 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAYSON | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 W 33RD ST | ||||||||
| Address2: | PBS 12TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100012603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123564474 | ||||||||
| FaxNumber: | 2123564608 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 W 12TH ST | ||||||||
| Address2: | MEDICINE/ GENERAL | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100118202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123564474 | ||||||||
| FaxNumber: | 2123564608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 03/29/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 143595 | NY | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 01009287 | 05 | NY | MEDICAID |