Provider Demographics
NPI:1407826910
Name:GRUSENMEYER, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:GRUSENMEYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26908 DETROIT RD
Mailing Address - Street 2:STE. 301
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2398
Mailing Address - Country:US
Mailing Address - Phone:440-617-1821
Mailing Address - Fax:
Practice Address - Street 1:26908 DETROIT RD
Practice Address - Street 2:STE. 201
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-2398
Practice Address - Country:US
Practice Address - Phone:440-777-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHG35048416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0673052Medicaid
OHH437041Medicare PIN
OH0673052Medicaid