Healthcare Provider Details

I. General information

NPI: 1245869858
Provider Name (Legal Business Name): GRANT EDLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 09/22/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

251 E HURON ST
CHICAGO IL
60611-2908
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number036.165111
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: