Basic Information
| Provider Information | |||||||||
| NPI: | 1699727347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREBENC | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5655 HUDSON DR STE 210 | ||||||||
| Address2: | ARIS RADIOLOGY | ||||||||
| City: | HUDSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442364455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306551869 | ||||||||
| FaxNumber: | 3306553828 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 ALVARADO RD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919413616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194602770 | ||||||||
| FaxNumber: | 6194602774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 11/02/2016 | ||||||||
| 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 | 2085R0202X | G87233 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G872330 | 01 | CA | BLUE SHIELD PIN | OTHER | 00G872330 | 05 | CA | MEDICAID |