MEDICARE: JAMES RICHARD GRUENEWALD PA-C

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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1750686796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES RICHARD GRUENEWALD PA-C

Provider Business Mailing Address
First Line	:	111 E WISCONSIN AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-4815
Country	:	US
Telephone Number	:	414-290-6700
Fax Number	:	414-290-6781

Provider Business Practice Location Address
First Line	:	111 E WISCONSIN AVE STE 2100
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-4809
Country	:	US
Telephone Number	:	414-290-6700
Fax Number	:	414-290-6781

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

Provider Enumeration Date	:	01/24/2011
Last Update Date	:	12/31/2021

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