MEDICARE: DR. WALTER R GROBELNY JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	036049787	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110006912	OTHER	IL	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1740275015
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALTER R GROBELNY JR. M.D.

Provider Business Mailing Address
First Line	:	700 OAK ST
Second Line	:	SUITE 200
City	:	WINNETKA
State	:	IL
Zip	:	60093-2566
Country	:	US
Telephone Number	:	847-446-1066
Fax Number	:	847-446-1825

Provider Business Practice Location Address
First Line	:	700 OAK ST
Second Line	:	SUITE 200
City	:	WINNETKA
State	:	IL
Zip	:	60093-2566
Country	:	US
Telephone Number	:	847-446-1066
Fax Number	:	847-446-1825

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	04/19/2011

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