=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205017597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILFREDO A GRANADA MD LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2007
-----------------------------------------------------
Last Update Date | 01/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2629 SHERIDAN RD SUITE C
-----------------------------------------------------
City | ZION
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60099-2629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-872-5556
-----------------------------------------------------
Fax | 847-872-5570
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2629 SHERIDAN RD SUITE C
-----------------------------------------------------
City | ZION
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60099-2629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-872-5556
-----------------------------------------------------
Fax | 847-872-5570
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. WILFREDO GRANADA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 847-872-5556
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------