Healthcare Provider Details

I. General information

NPI: 1194727909
Provider Name (Legal Business Name): MARK ALLEN GREVIOUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7905 CALUMET AVE
MUNSTER IN
46321-2549
US

IV. Provider business mailing address

849 W OHIO ST
CHICAGO IL
60642-6982
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-7506
  • Fax: 219-836-7515
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number036100551
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number01060561A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01060561A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036100551
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number036100551
License Number StateIL
# 6
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number72578
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: