Healthcare Provider Details

I. General information

NPI: 1992039747
Provider Name (Legal Business Name): PHYSICAL MEDICINE CLINIC OF GRANITE CITY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 10/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2861 MADISON AVE
GRANITE CITY IL
62040-3614
US

IV. Provider business mailing address

2861 MADISON AVE
GRANITE CITY IL
62040-3614
US

V. Phone/Fax

Practice location:
  • Phone: 618-877-4000
  • Fax: 618-877-0874
Mailing address:
  • Phone: 618-877-4000
  • Fax: 618-877-0874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209007631
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038009646
License Number StateIL

VIII. Authorized Official

Name: DR. BRIDGET BRASFIELD
Title or Position: OWNER/CHIROPRACTOR
Credential: D.C.
Phone: 618-877-4000