Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2084N0400X | Neurologist | 36064200 | IL |
N | 2084N0600X | Clinical Neurophysiologist | 36064200 | IL |
NPI | 1689640138 |
---|---|
Provider Name | Gregory Gruener |
First Address | Maywood, IL 60153 |
Second Address | Maywood, IL 60153 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/02/2006 |
Last Update Date | 11/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
36064200 | (05) | IL |
D13667 | (02) |