Healthcare Provider Details

I. General information

NPI: 1609040575
Provider Name (Legal Business Name): GRANT EDWARD GARRIGUES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 W HARRISON ST STE 400
CHICAGO IL
60612-4861
US

IV. Provider business mailing address

1 WESTBROOK CORPORATE CTR STE 240 ATTN: CREDENTIALING DEPT
WESTCHESTER IL
60154
US

V. Phone/Fax

Practice location:
  • Phone: 708-236-2600
  • Fax:
Mailing address:
  • Phone: 708-236-2673
  • Fax: 708-409-5179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD438684
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036-147187
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number01082491A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: