Provider Demographics
NPI:1457658841
Name:GRAND MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:GRAND MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-733-9858
Mailing Address - Street 1:2158 W GRAND AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1571
Mailing Address - Country:US
Mailing Address - Phone:312-733-9858
Mailing Address - Fax:312-799-8661
Practice Address - Street 1:2158 W GRAND AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-1571
Practice Address - Country:US
Practice Address - Phone:312-733-9858
Practice Address - Fax:312-799-8661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124389208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty