Basic Information
| Provider Information | |||||||||
| NPI: | 1598745085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIESBACK | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42 E LAUREL RD | ||||||||
| Address2: | UDP 3100 | ||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666859 | ||||||||
| FaxNumber: | 8565666952 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 E LAUREL RD | ||||||||
| Address2: | UDP 3100 | ||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666859 | ||||||||
| FaxNumber: | 8565666952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 04/27/2012 | ||||||||
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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 | 207RP1001X | MB02248100 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | MB02248100 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1853503 | 05 | NJ | MEDICAID |