Provider Demographics
NPI:1619147592
Name:PARK, GRACE LEE (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:LEE
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 S. LINCOLN AVE.
Mailing Address - Street 2:MCKINLEY HEALTH CENTER
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:217-333-2711
Mailing Address - Fax:
Practice Address - Street 1:1109 S. LINCOLN AVE.
Practice Address - Street 2:MCKINLEY HEALTH CENTER
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:217-333-2711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6447860004Medicare NSC
ILIL3270156Medicare PIN