Provider Demographics
NPI:1487910220
Name:DENNIS A GROLLO MDSC
Entity type:Organization
Organization Name:DENNIS A GROLLO MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GROLLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-362-2311
Mailing Address - Street 1:535 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2670
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:60048-2670
Practice Address - Country:US
Practice Address - Phone:847-362-2311
Practice Address - Fax:847-362-2369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057324207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty