Basic Information
| Provider Information | |||||||||
| NPI: | 1285602151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRUDZINSKI | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7150 W SUNSET RD STE 201A | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891131981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029021939 | ||||||||
| FaxNumber: | 7024421886 | ||||||||
| Practice Location | |||||||||
| Address1: | 7500 SMOKE RANCH RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022330727 | ||||||||
| FaxNumber: | 7022334799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 21055 | SC | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 20748 | NV | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 000000206911 | 01 | SC | UNISON HEALTH PLAN | OTHER | 5580793 | 01 | SC | AETNA | OTHER | P00360558 | 01 | SC | RAILROAD MEDICARE | OTHER | 771828 | 01 | SC | WELLCARE | OTHER | 80023030 | 01 | SC | SELECT HEALTH | OTHER | GP4522 | 05 | SC | MEDICAID | T50860 | 05 | SC | MEDICAID | 790598L | 01 | NC | EDS | OTHER | 8522204 | 01 | SC | CIGNA | OTHER | GP1521 | 05 | SC | MEDICAID | 2280313 | 01 | NC | CIGNA MEDICARE | OTHER | 5907458 | 05 | NC | MEDICAID |