Healthcare Provider Details

I. General information

NPI: 1083631006
Provider Name (Legal Business Name): MARY ELIZABETH GROLL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N CHILDRENS PLZ
CHICAGO IL
60614-3363
US

IV. Provider business mailing address

138 S KENILWORTH AVE
OAK PARK IL
60302-2815
US

V. Phone/Fax

Practice location:
  • Phone: 773-880-8277
  • Fax:
Mailing address:
  • Phone: 708-445-9120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: