Provider Demographics
NPI:1518282938
Name:GRENNAN, DARA
Entity Type:Individual
Prefix:DR
First Name:DARA
Middle Name:
Last Name:GRENNAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 N LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:312-956-8686
Mailing Address - Fax:
Practice Address - Street 1:403 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-285-5629
Practice Address - Fax:815-285-5634
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-137502207R00000X, 207RI0200X
UT8153445208M00000X
IL36.137502208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400440732OtherMEDICARE PTAN
IL036137502Medicaid