Healthcare Provider Details

I. General information

NPI: 1942952403
Provider Name (Legal Business Name): ALISON GRYCZEWSKI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 08/18/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 E MASON ST STE 4P57
SPRINGFIELD IL
62701-1034
US

IV. Provider business mailing address

619 E MASON ST STE 4P57
SPRINGFIELD IL
62701-1034
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-0706
  • Fax:
Mailing address:
  • Phone: 217-788-0706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008890
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: