Provider Demographics
NPI:1871587493
Name:GRUNDY, HOWARD O (MD)
Entity type:Individual
Prefix:
First Name:HOWARD
Middle Name:O
Last Name:GRUNDY
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 1:431 WESTMINSTER DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-8338
Mailing Address - Country:US
Mailing Address - Phone:219-864-2107
Mailing Address - Fax:219-864-2649
Practice Address - Street 1:24 JOLIET ST
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1705
Practice Address - Country:US
Practice Address - Phone:219-864-2036
Practice Address - Fax:219-864-2253
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037603A207V00000X
FLME159626207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100201440Medicaid
A44133Medicare UPIN
IN100201440Medicaid