=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164287017
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRZEGORZ SULOCHA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2024
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 SUPERIOR AVE
-----------------------------------------------------
City | MUNSTER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46321-4037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-922-4200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13917 W CANTIGNY LN
-----------------------------------------------------
City | HOMER GLEN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60491-5933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-250-3035
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835X0200X
-----------------------------------------------------
Taxonomy Name | Oncology Pharmacist
-----------------------------------------------------
License Number | 051293918
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------