Healthcare Provider Details

I. General information

NPI: 1922091412
Provider Name (Legal Business Name): TERESA E GRANT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E COUNTYLINE RD
SANDWICH IL
60548-2178
US

IV. Provider business mailing address

1 E COUNTYLINE RD
SANDWICH IL
60548-2178
US

V. Phone/Fax

Practice location:
  • Phone: 815-786-2722
  • Fax: 815-786-6840
Mailing address:
  • Phone: 815-786-2722
  • Fax: 815-786-6840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036111643
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036111643
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: