Provider Demographics
NPI:1306919147
Name:GROLLO, DENNIS ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:ANTHONY
Last Name:GROLLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DENNIS
Other - Middle Name:ANTHONY
Other - Last Name:GROLLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MDSC
Mailing Address - Street 1:535 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2600
Mailing Address - Country:US
Mailing Address - Phone:847-362-2311
Mailing Address - Fax:847-362-2369
Practice Address - Street 1:535 W PARK AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2600
Practice Address - Country:US
Practice Address - Phone:847-362-2311
Practice Address - Fax:847-362-2369
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC 48576Medicare UPIN
IL760-700Medicare ID - Type Unspecified