| NPI | 1205234291 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GRACE BLUE Credentialing Sr. Manager 773-292-4800 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine |
| Additional Taxonomies | 207QA0505X Family Medicine, Adult Medicine |
| 207QH0002X Family Medicine, Hospice and Palliative Medicine | |
| 207R00000X Internal Medicine | |
| 207RH0002X Internal Medicine, Hospice and Palliative Medicine | |
| 213E00000X Podiatrist | |
| 363L00000X Nurse Practitioner | |
| Enumeration Date | 2014-12-08 |
| Last Update Date | 2024-02-13 |