Basic Information
| Provider Information | |||||||||
| NPI: | 1952504169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIGORYEVA | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRIGORYEVE-POLOUNIN | ||||||||
| OtherFirstName: | ANNA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 785 5TH AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7177096529 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 ST PAUL DRIVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172011036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172176870 | ||||||||
| FaxNumber: | 7172176945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | MD435059 | PA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | P00741669 | 01 | PA | RAILROAD MEDICARE | OTHER | 25-1716306 | 01 | PA | INTERGROUP | OTHER | 25-1716306 | 01 | PA | HEALTH AMERICA | OTHER | 102323756 0001 | 05 | PA | MEDICAID | 50086443 | 01 | PA | CAPITAL BLUECROSS | OTHER | MD435059 | 01 | PA | LICENSE | OTHER | 25-1716306 | 01 | PA | SOUTH CENTRAL PREFERRED | OTHER | FG0407610 | 01 | PA | DEA | OTHER | GR2105179 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 25-1716306 | 01 | PA | GREATWEST | OTHER | 25-1716306 | 01 | PA | FIRST HEALTH | OTHER | 25-1716306 | 01 | PA | DEVON | OTHER | G920-0120/KDM4CU | 01 | PA | CAREFIRST | OTHER | 2212067 | 01 | PA | MAMSI | OTHER | 25-1716306 | 01 | PA | INFORMED | OTHER | 25-1716306 | 01 | PA | MULTIPLAN/PHCS | OTHER | 276094 | 01 | PA | UNISON | OTHER | 867633 | 01 | PA | MEDICARE GROUP # | OTHER | 9214076 | 01 | PA | AETNA NON-HMO | OTHER | 120420405 | 01 | PA | DEPT OF LABOR | OTHER | 25-1716306 | 01 | PA | HEALTHNET/TRICARE | OTHER | 6955538 | 01 | PA | AETNA HMO | OTHER |