1255387957 NPI number — GRANITE CITY CLINIC CORP

Table of content: (NPI 1255387957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255387957 NPI number — GRANITE CITY CLINIC CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANITE CITY CLINIC CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255387957
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1573 MALLORY LN STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-2895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-221-1400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2044 MADISON AVE
Provider Second Line Business Practice Location Address:
SUITE 27
Provider Business Practice Location Address City Name:
GRANITE CITY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62040-4641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-451-7600
Provider Business Practice Location Address Fax Number:
618-451-7685
Provider Enumeration Date:
05/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FEY
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
SR. DIRECTOR PHYSICIAN REV CYCLE
Authorized Official Telephone Number:
615-221-3641

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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