MEDICARE: DR. JON MARK GRUDEM MD

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	2084N0400X	Neurology Physician	7354	SD
2	2084N0400X	Neurology Physician	38576	IA

General Provider Information

NPI Number	:	1477649531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON MARK GRUDEM MD

Provider Business Mailing Address
First Line	:	575 N SIOUX POINT RD
Second Line	:
City	:	NORTH SIOUX CITY
State	:	SD
Zip	:	57049-5312
Country	:	US
Telephone Number	:	605-217-2667
Fax Number	:	605-217-2900

Provider Business Practice Location Address
First Line	:	575 N SIOUX POINT RD
Second Line	:
City	:	NORTH SIOUX CITY
State	:	SD
Zip	:	57049-5312
Country	:	US
Telephone Number	:	605-217-2667
Fax Number	:	605-217-2900

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

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	01/13/2011

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