Healthcare Provider Details

I. General information

NPI: 1760643167
Provider Name (Legal Business Name): GRACE GEORGE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 ERIE CT SUITE L-700
OAK PARK IL
60302-2519
US

IV. Provider business mailing address

3 ERIE CT SUITE L-700
OAK PARK IL
60302-2519
US

V. Phone/Fax

Practice location:
  • Phone: 708-763-1222
  • Fax: 708-763-1471
Mailing address:
  • Phone: 708-763-1222
  • Fax: 708-763-1471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01073229A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125055167
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: