Provider Demographics
NPI:1659861953
Name:GRANITE CITY URGENT CARE WALK-IN CLINIC
Entity Type:Organization
Organization Name:GRANITE CITY URGENT CARE WALK-IN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RIZWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-317-0600
Mailing Address - Street 1:2861 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-3614
Mailing Address - Country:US
Mailing Address - Phone:618-709-7723
Mailing Address - Fax:618-709-7706
Practice Address - Street 1:2861 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3614
Practice Address - Country:US
Practice Address - Phone:734-771-8504
Practice Address - Fax:313-948-3041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-14
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207R00000X
261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty