Provider Demographics
NPI:1770563702
Name:GROSSKOPF, JEFFREY W (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:W
Last Name:GROSSKOPF
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 1:3805 E. MAIN STREET
Mailing Address - Street 2:SUITE G
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174
Mailing Address - Country:US
Mailing Address - Phone:630-402-2128
Mailing Address - Fax:630-397-7814
Practice Address - Street 1:3805 E. MAIN STREET
Practice Address - Street 2:SUITE G
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174
Practice Address - Country:US
Practice Address - Phone:630-402-2128
Practice Address - Fax:630-397-7814
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066604207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
200007877OtherRAILROAD MEDICARE
ILCF2064OtherRAIL GROUP
C44349Medicare UPIN
P10071Medicare PIN
ILCF2064OtherRAIL GROUP
753210Medicare ID - Type Unspecified