| NPI | 1386041234 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GRACE BLUE Credentialing Sr. Manager 773-292-4800 |
| Organization Subpart ? | No |
| Primary Taxonomy | 208D00000X General Practice |
| Additional Taxonomies | 213E00000X Podiatrist |
| 363LA2200X Nurse Practitioner, Adult Health | |
| Enumeration Date | 2014-11-20 |
| Last Update Date | 2024-02-13 |