MEDICARE: GRANITE CITY PHYSICIANS CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1073567483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANITE CITY PHYSICIANS CORP

Provider Business Mailing Address
First Line	:	1573 MALLORY LN STE 100
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-2895
Country	:	US
Telephone Number	:	152-221-1400
Fax Number	:	618-628-6877

Provider Business Practice Location Address
First Line	:	2044 MADISON AVE
Second Line	:	SUITE 15
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-4641
Country	:	US
Telephone Number	:	618-798-8652
Fax Number	:	618-798-8116

Authorized Official
Title or Position	:	SR. DIRECTOR PHYSICIAN REV CYCLE
Name	:	LAURA J FEY
Credential	:
Telephone Number	:	615-221-3641

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	07/07/2023

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Practice Location Address:

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Directions to “GRANITE CITY PHYSICIANS CORP ” Practice Location

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