| NPI | 1174874200 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GRACE V BLUE Credentialing Sr. Manager 773-292-4800 |
| Organization Subpart ? | No |
| Primary Taxonomy | 208D00000X General Practice |
| Additional Taxonomies | 207Q00000X Family Medicine |
| Enumeration Date | 2012-09-28 |
| Last Update Date | 2024-01-16 |