Provider Demographics
NPI:1487761367
Name:GRUSZKA, BERNIE
Entity type:Individual
Prefix:
First Name:BERNIE
Middle Name:
Last Name:GRUSZKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12116 MONTOUR DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-4317
Mailing Address - Country:US
Mailing Address - Phone:314-822-1099
Mailing Address - Fax:
Practice Address - Street 1:12382 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6443
Practice Address - Country:US
Practice Address - Phone:314-453-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOR0074OtherLICENSE #