Provider Demographics
NPI:1922669670
Name:DR 247 SC
Entity Type:Organization
Organization Name:DR 247 SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANOVSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:847-949-3913
Mailing Address - Street 1:975 WEILAND RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-7053
Mailing Address - Country:US
Mailing Address - Phone:847-947-8444
Mailing Address - Fax:847-947-8435
Practice Address - Street 1:975 WEILAND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-7053
Practice Address - Country:US
Practice Address - Phone:847-947-8444
Practice Address - Fax:847-947-8435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-24
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty