Basic Information
| Provider Information | |||||||||
| NPI: | 1578561718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRUENTHAL | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 47 NEW SCOTLAND AVE | ||||||||
| Address2: | ALBANY MEDICAL COLLEGE, MC70 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122083412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182622754 | ||||||||
| FaxNumber: | 5182626261 | ||||||||
| Practice Location | |||||||||
| Address1: | 47 NEW SCOTLAND AVE | ||||||||
| Address2: | ALBANY MEDICAL COLLEGE, MC70 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122083412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182622754 | ||||||||
| FaxNumber: | 5182626261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 10/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 239220 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | 239220 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
| ID | Type | State | Issuer | Description | 64273188 | 05 | KY | MEDICAID |