1720055320 NPI number — DAVID B GRANATO MD

Table of content: DAVID B GRANATO MD (NPI 1720055320)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720055320 NPI number — DAVID B GRANATO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANATO
Provider First Name:
DAVID
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1720055320
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6910 S MADISON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLOWBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-321-2788
Provider Business Mailing Address Fax Number:
630-323-1699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1455 GOLF RD
Provider Second Line Business Practice Location Address:
STE 212
Provider Business Practice Location Address City Name:
DES PLAINES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-297-1800
Provider Business Practice Location Address Fax Number:
847-297-2757
Provider Enumeration Date:
03/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  036080275 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300024281 . This is a "RR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 036080275 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: CN0576 . This is a "GR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1615479 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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