Provider Demographics
NPI:1184614026
Name:THUNDIYIL, GRACE MURICKEN (MD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:MURICKEN
Last Name:THUNDIYIL
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3619 STUBAI TRL
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-7336
Mailing Address - Country:US
Mailing Address - Phone:815-987-7032
Mailing Address - Fax:815-987-7670
Practice Address - Street 1:4402 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-1278
Practice Address - Country:US
Practice Address - Phone:815-987-7032
Practice Address - Fax:815-987-7670
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC48488Medicare UPIN