Healthcare Provider Details

I. General information

NPI: 1558368043
Provider Name (Legal Business Name): NANCY GRYNIEWICZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 LAKE ST
OAK PARK IL
60301-1292
US

IV. Provider business mailing address

965 LAKE ST
OAK PARK IL
60301-1292
US

V. Phone/Fax

Practice location:
  • Phone: 708-383-0400
  • Fax: 708-383-4314
Mailing address:
  • Phone: 708-383-0400
  • Fax: 708-383-4314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036089707
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: