Provider Demographics
NPI:1598248106
Name:GRANITE CITY CLINIC CORP
Entity Type:Organization
Organization Name:GRANITE CITY CLINIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PRACTICE MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:ZACH
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:CHAPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-798-3845
Mailing Address - Street 1:2100 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4713
Mailing Address - Country:US
Mailing Address - Phone:618-798-3845
Mailing Address - Fax:
Practice Address - Street 1:602 FARRISH ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IL
Practice Address - Zip Code:62060-1567
Practice Address - Country:US
Practice Address - Phone:618-501-6261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANITE CITY CLINIC CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care