| NPI | 1861094534 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GRACE V BLUE Credentialing Sr Manager 773-292-4800 |
| Organization Subpart ? | No |
| Primary Taxonomy | 208D00000X General Practice |
| Additional Taxonomies | 207R00000X Internal Medicine |
| Enumeration Date | 2020-11-09 |
| Last Update Date | 2024-05-07 |