Provider Demographics
NPI:1659539203
Name:GREAT RIVER COMMUNITY MEDICAL CLINIC SC
Entity Type:Organization
Organization Name:GREAT RIVER COMMUNITY MEDICAL CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRUNWALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-326-5459
Mailing Address - Street 1:100 N MARQUETTE RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:PRAIRIE DU CHIEN
Mailing Address - State:WI
Mailing Address - Zip Code:53821
Mailing Address - Country:US
Mailing Address - Phone:608-326-1072
Mailing Address - Fax:608-326-1076
Practice Address - Street 1:100 N MARQUETTE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821
Practice Address - Country:US
Practice Address - Phone:608-326-1072
Practice Address - Fax:608-326-1076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23439207Q00000X
WI23379207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty