Healthcare Provider Details

I. General information

NPI: 1831265016
Provider Name (Legal Business Name): NOEL GRANDAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 S 5TH AVE
HINES IL
60141-3030
US

IV. Provider business mailing address

5000 S 5TH AVE
HINES IL
60141-3030
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-2282
  • Fax: 708-202-2281
Mailing address:
  • Phone: 708-202-2282
  • Fax: 708-202-2281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number036113697
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: