Healthcare Provider Details

I. General information

NPI: 1215074869
Provider Name (Legal Business Name): GRISELDA HERNANDEZ RAHMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 SUPERIOR ST SUITE 302
MELROSE PARK IL
60160-4138
US

IV. Provider business mailing address

6065 S 76TH AVE
SUMMIT IL
60501-1533
US

V. Phone/Fax

Practice location:
  • Phone: 708-344-0808
  • Fax: 708-344-5055
Mailing address:
  • Phone: 708-496-0351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number85002784
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: