Healthcare Provider Details

I. General information

NPI: 1003892464
Provider Name (Legal Business Name): GRANITE CITY CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 MADISON AVE
GRANITE CITY IL
62040-4701
US

IV. Provider business mailing address

P O BOX 503734
SAINT LOUIS MO
63150-0001
US

V. Phone/Fax

Practice location:
  • Phone: 618-798-3000
  • Fax:
Mailing address:
  • Phone: 660-826-5960
  • Fax: 660-826-4852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: GARY NEWSOME
Title or Position: VP
Credential:
Phone: 615-465-7000