Provider Demographics
NPI:1134141526
Name:GROSEL, MARK C (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:GROSEL
Suffix:
Gender:M
Credentials:PT
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 081433
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53408-1433
Mailing Address - Country:US
Mailing Address - Phone:262-321-0240
Mailing Address - Fax:262-321-0242
Practice Address - Street 1:237 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4955
Practice Address - Country:US
Practice Address - Phone:262-321-0240
Practice Address - Fax:262-321-0242
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1891-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40166200Medicaid
WI00008150/0010Medicare ID - Type Unspecified