Provider Demographics
NPI:1558368043
Name:GRYNIEWICZ, NANCY (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:GRYNIEWICZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1292
Mailing Address - Country:US
Mailing Address - Phone:708-383-0400
Mailing Address - Fax:708-383-4314
Practice Address - Street 1:965 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1292
Practice Address - Country:US
Practice Address - Phone:708-383-0400
Practice Address - Fax:708-383-4314
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089707207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203395Medicare ID - Type Unspecified
ILG16478Medicare UPIN