Provider Demographics
NPI:1588779763
Name:GRYFINSKI, MARTIN EDWARD (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:EDWARD
Last Name:GRYFINSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:779-696-7342
Practice Address - Street 1:1340 CHARLES ST
Practice Address - Street 2:SUITE 400
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104
Practice Address - Country:US
Practice Address - Phone:779-696-9512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-071919207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071919Medicaid
IL01915166OtherBLUE CROSS/BLUE SHIELD
IL197958OtherHEALTH ALLIANCE
ILP00971760OtherRAILROAD MEDICARE
ILF400201371Medicare PIN
IL197958OtherHEALTH ALLIANCE