Provider Demographics
NPI:1083766372
Name:GRANDINETTI, PHILIP G (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:G
Last Name:GRANDINETTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6322 N CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-4422
Mailing Address - Country:US
Mailing Address - Phone:773-736-8088
Mailing Address - Fax:
Practice Address - Street 1:6322 N CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-4422
Practice Address - Country:US
Practice Address - Phone:773-736-8088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087271207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087271Medicaid
IL01605424OtherBLUE CROSS BLUE SHEILD OF
IL036087271Medicaid
ILF85194Medicare UPIN