Provider Demographics
NPI:1205017597
Name:WILFREDO A GRANADA MD LTD
Entity Type:Organization
Organization Name:WILFREDO A GRANADA MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILFREDO
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-872-5556
Mailing Address - Street 1:2629 SHERIDAN RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-2629
Mailing Address - Country:US
Mailing Address - Phone:847-872-5556
Mailing Address - Fax:847-872-5570
Practice Address - Street 1:2629 SHERIDAN RD
Practice Address - Street 2:SUITE C
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-2629
Practice Address - Country:US
Practice Address - Phone:847-872-5556
Practice Address - Fax:847-872-5570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212858OtherMEDICARE
IL21604808OtherBLUE CROSS
IL21604808OtherBLUE CROSS