Provider Demographics
NPI:1104933944
Name:GROTHENDIECK, CAMPSIE
Entity type:Individual
Prefix:
First Name:CAMPSIE
Middle Name:
Last Name:GROTHENDIECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10024 SKOKIE BLVD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-9944
Mailing Address - Country:US
Mailing Address - Phone:847-677-8577
Mailing Address - Fax:847-677-8574
Practice Address - Street 1:10024 SKOKIE BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-9944
Practice Address - Country:US
Practice Address - Phone:847-677-8577
Practice Address - Fax:847-677-8574
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000404363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ47754Medicare UPIN