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General NPI Number Information
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NPI Number | 1598248106
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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 | 09/10/2018
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Last Update Date | 09/10/2018
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Provider Practice Location Address
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Address Line | 602 FARRISH ST
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City | MADISON
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State | IL
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Zip | 62060-1567
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Country | US
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Telephone | 618-501-6261
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Fax |
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Provider Business Mailing 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 | 62040-4713
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Country | US
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Telephone | 618-798-3845
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Fax |
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Authorized Official
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Title or Position | DIRECTOR PRACTICE MANAGEMENT
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Name | ZACH KENNETH CHAPMAN
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Credential |
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Telephone | 618-798-3845
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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