Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 036075647 | IL |
NPI | 1316219546 |
---|---|
Provider Name | Mark Grant |
First Address | Chicago, IL 60601-7757 |
Second Address | Chicago, IL 60601-7757 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/02/2012 |
Last Update Date | 03/02/2012 |