Provider Demographics
NPI:1255622163
Name:GROSSKOPF ORTHOPEDIC SC
Entity type:Organization
Organization Name:GROSSKOPF ORTHOPEDIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:GROSSKOPF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-402-2128
Mailing Address - Street 1:3805 E MAIN ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2487
Mailing Address - Country:US
Mailing Address - Phone:630-402-2128
Mailing Address - Fax:630-397-7814
Practice Address - Street 1:3805 E MAIN ST
Practice Address - Street 2:SUITE G
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2487
Practice Address - Country:US
Practice Address - Phone:630-402-2128
Practice Address - Fax:630-397-7814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066604207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC44349OtherUPIN