Healthcare Provider Details

I. General information

NPI: 1871587493
Provider Name (Legal Business Name): HOWARD O GRUNDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 JOLIET ST
DYER IN
46311-1705
US

IV. Provider business mailing address

431 WESTMINSTER DR
BURR RIDGE IL
60527-8338
US

V. Phone/Fax

Practice location:
  • Phone: 219-864-2036
  • Fax: 219-864-2253
Mailing address:
  • Phone: 219-864-2107
  • Fax: 219-864-2649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01037603A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberME159626
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: