MEDICARE: DR. PHILIP G GRANDINETTI 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	207Q00000X	Family Medicine Physician	036087271	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
2	01605424	OTHER	IL	BLUE CROSS BLUE SHEILD OF

General Provider Information

NPI Number	:	1083766372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILIP G GRANDINETTI M.D.

Provider Business Mailing Address
First Line	:	6322 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-4422
Country	:	US
Telephone Number	:	773-736-8088
Fax Number	:

Provider Business Practice Location Address
First Line	:	6322 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-4422
Country	:	US
Telephone Number	:	773-736-8088
Fax Number	:

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

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	12/02/2009

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