Healthcare Provider Details

I. General information

NPI: 1750030599
Provider Name (Legal Business Name): KELSEA RENEE GRANT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE # MC2050
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

180 HARVESTER DR. STE 110
BURR RIDGE IL
60527-6686
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-6118
  • Fax: 773-702-0840
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number036.179564
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: