Basic Information
| Provider Information | |||||||||
| NPI: | 1760999783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRUCHALSKI | ||||||||
| FirstName: | BERNADETTE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOJEK | ||||||||
| OtherFirstName: | BERNADETTE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 27702 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088627674 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 19550 GOVERNORS HWY STE 2350 | ||||||||
| Address2: | |||||||||
| City: | FLOSSMOOR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604222125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087980200 | ||||||||
| FaxNumber: | 7087980205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2017 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209017051 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.