Provider Demographics
NPI:1760999783
Name:GRUCHALSKI, BERNADETTE (NP-C)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:GRUCHALSKI
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:BERNADETTE
Other - Middle Name:
Other - Last Name:LOJEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27702 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1256
Mailing Address - Country:US
Mailing Address - Phone:708-862-7674
Mailing Address - Fax:
Practice Address - Street 1:19550 GOVERNORS HWY STE 2350
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2125
Practice Address - Country:US
Practice Address - Phone:708-798-0200
Practice Address - Fax:708-798-0205
Is Sole Proprietor?:No
Enumeration Date:2017-12-30
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017051363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid