Provider Demographics
NPI:1073506101
Name:GRUSZKA, MARY ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:GRUSZKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8711 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:NORTH RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-1166
Practice Address - Country:US
Practice Address - Phone:708-442-7979
Practice Address - Fax:708-442-8574
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061958208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061958Medicaid