Provider Demographics
NPI:1548658982
Name:GRUDSKY, IRENE
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:GRUDSKY
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 1:6384 SHADYVIEW LANE NORTH
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311
Mailing Address - Country:US
Mailing Address - Phone:763-222-8051
Mailing Address - Fax:
Practice Address - Street 1:10550 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305
Practice Address - Country:US
Practice Address - Phone:763-694-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1075653171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor