Provider Demographics
NPI:1710039847
Name:GRUNBERG, IAN (DC)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:GRUNBERG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1386 7TH ST W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-4206
Mailing Address - Country:US
Mailing Address - Phone:651-293-9200
Mailing Address - Fax:651-228-7103
Practice Address - Street 1:1386 7TH ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-4206
Practice Address - Country:US
Practice Address - Phone:651-293-9200
Practice Address - Fax:651-228-7103
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1485111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1D238GROtherBCBSM
MN1D238GROtherBCBSM