MEDICARE: DR. KENNETH A GRUMET M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	036063903	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1275564940	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1275564940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH A GRUMET M.D.

Provider Business Mailing Address
First Line	:	1000 REMINGTON BLVD STE 100
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4707
Country	:	US
Telephone Number	:	630-914-2898
Fax Number	:	630-914-2469

Provider Business Practice Location Address
First Line	:	800 AUSTIN ST STE 451
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60202-3455
Country	:	US
Telephone Number	:	847-316-6600
Fax Number	:	847-316-6606

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	03/17/2021

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