Healthcare Provider Details

I. General information

NPI: 1255387957
Provider Name (Legal Business Name): GRANITE CITY CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2044 MADISON AVE SUITE 27
GRANITE CITY IL
62040-4641
US

IV. Provider business mailing address

1573 MALLORY LN STE 100
BRENTWOOD TN
37027-2895
US

V. Phone/Fax

Practice location:
  • Phone: 618-451-7600
  • Fax: 618-451-7685
Mailing address:
  • Phone: 615-221-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

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