MEDICARE: GRANT ADVOCATE ILLINOIS LLC

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	036119674	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376871020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANT ADVOCATE ILLINOIS LLC

Provider Business Mailing Address
First Line	:	441 E ERIE ST
Second Line	:	SUITE 3712
City	:	CHICAGO
State	:	IL
Zip	:	60611-4446
Country	:	US
Telephone Number	:	773-816-1117
Fax Number	:	773-751-2250

Provider Business Practice Location Address
First Line	:	441 E ERIE ST
Second Line	:	SUITE 3712
City	:	CHICAGO
State	:	IL
Zip	:	60611-4446
Country	:	US
Telephone Number	:	773-816-1117
Fax Number	:	773-751-2250

Authorized Official
Title or Position	:	PRES
Name	:	DR. JERISA JOHNSON
Credential	:	DO
Telephone Number	:	773-816-1117

Provider Enumeration Date	:	11/18/2009
Last Update Date	:	11/18/2009

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