Provider Demographics
NPI:1437116357
Name:GRUENWALD, LEE M (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:M
Last Name:GRUENWALD
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 1:4065 N 35TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-1705
Mailing Address - Country:US
Mailing Address - Phone:414-445-9180
Mailing Address - Fax:414-445-5995
Practice Address - Street 1:4065 N 35TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1705
Practice Address - Country:US
Practice Address - Phone:414-445-9180
Practice Address - Fax:414-445-5995
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI444312084P0804X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34276900Medicaid
WI34276900Medicaid