| NPI | 1700529120 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GRACE BLUE Credentialing Sr. Manager 773-292-4800 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine |
| Additional Taxonomies | 207RH0002X Internal Medicine, Hospice and Palliative Medicine |
| 207Q00000X Family Medicine | |
| 207QH0002X Family Medicine, Hospice and Palliative Medicine | |
| Enumeration Date | 2022-04-14 |
| Last Update Date | 2023-12-13 |