Basic Information
| Provider Information | |||||||||
| NPI: | 1043418544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRUDZEN | ||||||||
| FirstName: | CORITA | ||||||||
| MiddleName: | REILLEY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 550 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100166402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122633293 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 550 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100166402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122633293 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 05/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A91053 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 233941-1 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 070913000141 | 01 | FIDELISCARE OF NY | OTHER | 6007526 | 01 | MVP HEALTHPLAN PIN # | OTHER | 7243967 | 01 | AETNA PPO # | OTHER | 1591896 | 01 | AETNA HMO PIN # | OTHER | 3592Q1 | 01 | EMPIRE BC BS | OTHER | 0170035 | 01 | GHI PPO PIN # | OTHER | 10127536 | 01 | CDPHP PIN # | OTHER | 6C5394 | 01 | HEALTHNET PIN # | OTHER | 000000120752 | 01 | GHI HMO PIN# | OTHER |