Healthcare Provider Details

I. General information

NPI: 1942315197
Provider Name (Legal Business Name): GRAHAM SERVICES CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 S MAIN ST
CANTON IL
61520-2670
US

IV. Provider business mailing address

175 S MAIN ST
CANTON IL
61520-2670
US

V. Phone/Fax

Practice location:
  • Phone: 309-647-0201
  • Fax: 309-647-0201
Mailing address:
  • Phone: 309-647-0201
  • Fax: 309-647-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. CHRIS DUVENDACK
Title or Position: VP OF CLINIC OPERATIONS
Credential:
Phone: 309-647-0201