Provider Demographics
NPI:1083643647
Name:GRUMISH, JOHN PAUL (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PAUL
Last Name:GRUMISH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 BRIARCLIFF PROFESSIONAL CENTER
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1775
Mailing Address - Country:US
Mailing Address - Phone:815-939-0990
Mailing Address - Fax:815-939-0822
Practice Address - Street 1:40 BRIARCLIFF PROFESSIONAL CENTER
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1775
Practice Address - Country:US
Practice Address - Phone:815-939-0990
Practice Address - Fax:815-939-0822
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-003849111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038007503Medicaid
IL350009461OtherRAILROAD MEDICARE NUMBER
IL038003849Medicaid
T37183Medicare UPIN
ILL72848Medicare PIN