Basic Information
Provider Information | |||||||||
NPI: | 1417904210 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRIES | ||||||||
FirstName: | CYNTHIA | ||||||||
MiddleName: | JANE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., MSC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DE RUITER | ||||||||
OtherFirstName: | CYNTHIA | ||||||||
OtherMiddleName: | JANE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2415 N ORANGE AVE | ||||||||
Address2: | SUITE 700 | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328045505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073032474 | ||||||||
FaxNumber: | 4073030678 | ||||||||
Practice Location | |||||||||
Address1: | 2415 N ORANGE AVE | ||||||||
Address2: | SUITE 700 | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328045505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073032474 | ||||||||
FaxNumber: | 4073030678 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2006 | ||||||||
LastUpdateDate: | 10/16/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | MD438817 | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207R00000X | MD438817 | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RP1001X | MD438817 | PA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 8436438 | 05 | WA |   | MEDICAID |