| NPI | 1417235359 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GRACE BLUE Credentialing Sr. Manager 773-292-4800 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine |
| Additional Taxonomies | 207Q00000X Family Medicine |
| 213E00000X Podiatrist | |
| 363A00000X Physician Assistant | |
| 363L00000X Nurse Practitioner | |
| Enumeration Date | 2011-07-26 |
| Last Update Date | 2025-03-20 |