Healthcare Provider Details

I. General information

NPI: 1558706168
Provider Name (Legal Business Name): ERIN COLLEEN GRGURICH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ERIN TAFT D.O.

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

IV. Provider business mailing address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

V. Phone/Fax

Practice location:
  • Phone: 217-223-8400
  • Fax:
Mailing address:
  • Phone: 217-223-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036143218
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2020015152
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: