Healthcare Provider Details

I. General information

NPI: 1629031141
Provider Name (Legal Business Name): DONALD JOSEPH GRUNZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD DEPT OF RADIOLOGY
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

11475 OLDE CABIN RD SUITE200
SAINT LOUIS MO
63141-7128
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6031
  • Fax: 314-251-6343
Mailing address:
  • Phone: 314-991-8200
  • Fax: 314-991-8206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number101906
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number101906
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: