Provider Demographics
NPI:1093980872
Name:GRUNER, CHARLES R (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:GRUNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:800 AUSTIN ST
Mailing Address - Street 2:EAST TOWER, SUITE 563
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3439
Mailing Address - Country:US
Mailing Address - Phone:847-869-0522
Mailing Address - Fax:847-869-0652
Practice Address - Street 1:800 AUSTIN ST
Practice Address - Street 2:EAST TOWER, SUITE 563
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3439
Practice Address - Country:US
Practice Address - Phone:847-869-0522
Practice Address - Fax:847-869-0652
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115417208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115417Medicaid