MEDICARE: DEAN A GRAVLIN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	036057930	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053315861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEAN A GRAVLIN M.D.

Provider Business Mailing Address
First Line	:	200 E PENNSYLVANIA AVE
Second Line	:	STE 105
City	:	PEORIA
State	:	IL
Zip	:	61603-3045
Country	:	US
Telephone Number	:	309-655-7888
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 E PENNSYLVANIA AVE
Second Line	:	STE 105
City	:	PEORIA
State	:	IL
Zip	:	61603-3045
Country	:	US
Telephone Number	:	309-655-7888
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	08/17/2012

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Directions to “ DEAN A GRAVLIN M.D.” Practice Location

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