Provider Demographics
NPI:1336855329
Name:GRONAU, CHARLES GORDON II (ACSM EP-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:GORDON
Last Name:GRONAU
Suffix:II
Gender:M
Credentials:ACSM EP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E 9TH ST APT 512
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2142
Mailing Address - Country:US
Mailing Address - Phone:618-746-6956
Mailing Address - Fax:
Practice Address - Street 1:1640 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1316
Practice Address - Country:US
Practice Address - Phone:312-413-8043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1069105224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist