Healthcare Provider Details

I. General information

NPI: 1508810920
Provider Name (Legal Business Name): GRANITE CITY ORTHOPEDIC PHYSICIANS COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 S STATE ROUTE 159
GLEN CARBON IL
62034-1904
US

IV. Provider business mailing address

1573 MALLORY LN STE 100
BRENTWOOD TN
37027-2895
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-4388
  • Fax: 618-288-4927
Mailing address:
  • Phone: 615-221-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAURA J FEY
Title or Position: SR. DIRECTOR PHYSICIAN REV CYCLE
Credential:
Phone: 615-221-3641