MEDICARE: DR. JONATHAN JAY GRUSSING D.C.

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	111N00000X	Chiropractor	3280	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	129MOGR	OTHER	MN	BCBS INDIVIDUAL ID
2	128M9HE	OTHER	MN	BCBS GROUP ID NUMBER

General Provider Information

NPI Number	:	1710022348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN JAY GRUSSING D.C.

Provider Business Mailing Address
First Line	:	23 NORTH MAIN STREET
Second Line	:	P.O. BOX 793
City	:	CLARA CITY
State	:	MN
Zip	:	56222-0793
Country	:	US
Telephone Number	:	320-847-3511
Fax Number	:	320-847-3752

Provider Business Practice Location Address
First Line	:	23 NORTH MAIN STREET
Second Line	:
City	:	CLARA CITY
State	:	MN
Zip	:	56222-0793
Country	:	US
Telephone Number	:	320-847-3511
Fax Number	:	320-847-3752

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

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/09/2007

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