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General NPI Number Information
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NPI Number | 1003892464
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Entity Type | Organization
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Legal Business Name | GRANITE CITY CLINIC CORP
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Dates
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Enumeration Date | 12/19/2005
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Last Update Date | 07/30/2007
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Provider Practice Location Address
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Address Line | 2100 MADISON AVE
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City | GRANITE CITY
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State | IL
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Zip | 62040-4701
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Country | US
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Telephone | 618-798-3000
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Fax |
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Provider Business Mailing Address
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Address Line | P O BOX 503734
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City | SAINT LOUIS
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State | MO
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Zip | 63150-0001
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Country | US
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Telephone | 660-826-5960
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Fax | 660-826-4852
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Authorized Official
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Title or Position | VP
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Name | GARY NEWSOME
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Credential |
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Telephone | 615-465-7000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number |
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License Number State |
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