Provider Demographics
NPI:1700850625
Name:GRELA, JACEK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACEK
Middle Name:
Last Name:GRELA
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 1:10S570 GLENN DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6822
Mailing Address - Country:US
Mailing Address - Phone:708-636-1601
Mailing Address - Fax:708-636-1825
Practice Address - Street 1:1011 STATE ST
Practice Address - Street 2:SUITE 140
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-4768
Practice Address - Country:US
Practice Address - Phone:630-754-0141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098225207R00000X
IL036-098225207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098225Medicaid
ILH02803Medicare UPIN
ILK24707Medicare ID - Type UnspecifiedMEDICARE