Provider Demographics
NPI:1447508437
Name:GRINCEWICZ, BRADLEY L (PA-C)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:L
Last Name:GRINCEWICZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31700 VAN DYKE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-7951
Mailing Address - Country:US
Mailing Address - Phone:586-693-0431
Mailing Address - Fax:586-693-0432
Practice Address - Street 1:31700 VAN DYKE AVE STE 100
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-7951
Practice Address - Country:US
Practice Address - Phone:586-693-0431
Practice Address - Fax:586-693-0432
Is Sole Proprietor?:No
Enumeration Date:2012-08-22
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700E04360OtherBLUE CROSS BLUE SHIELDS OF MICHIGAN
MIMI8102025Medicare PIN