Healthcare Provider Details

I. General information

NPI: 1710118252
Provider Name (Legal Business Name): GRACE WOMEN'S HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 01/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S 3RD ST SUITE 200
BELLEVILLE IL
62220-1952
US

IV. Provider business mailing address

180 S 3RD ST SUITE 200
BELLEVILLE IL
62220-1952
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-0017
  • Fax: 618-233-0251
Mailing address:
  • Phone: 618-233-0017
  • Fax: 618-233-0251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH J RAU
Title or Position: ASSISTANT OFFICE MANAGER
Credential:
Phone: 618-233-0017