Provider Demographics
NPI:1992039747
Name:PHYSICAL MEDICINE CLINIC OF GRANITE CITY LTD
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE CLINIC OF GRANITE CITY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:BRASFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-877-4000
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:618-877-4000
Mailing Address - Fax:618-877-0874
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:618-877-4000
Practice Address - Fax:618-877-0874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009646111N00000X
IL209007631363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6470500001Medicare NSC