Provider Demographics
NPI:1972656890
Name:DR. MICHAEL H. GROUSD DDS MA LTD
Entity Type:Organization
Organization Name:DR. MICHAEL H. GROUSD DDS MA LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCMANAMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-367-4190
Mailing Address - Street 1:1 E PHILLIP RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1858
Mailing Address - Country:US
Mailing Address - Phone:847-367-4190
Mailing Address - Fax:847-367-5010
Practice Address - Street 1:1 E PHILLIP RD
Practice Address - Street 2:SUITE 101
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1858
Practice Address - Country:US
Practice Address - Phone:847-367-4190
Practice Address - Fax:847-367-5010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL80022385OtherBLUE CROSS BLUE SHIELD
IL80022385OtherBLUE CROSS BLUE SHIELD
212325Medicare ID - Type Unspecified