Provider Demographics
NPI:1457405300
Name:GRACE MEDICAL CENTER, SC
Entity Type:Organization
Organization Name:GRACE MEDICAL CENTER, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUNG
Authorized Official - Middle Name:S
Authorized Official - Last Name:RIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-854-5533
Mailing Address - Street 1:2250 W ALGONQUIN RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-1289
Mailing Address - Country:US
Mailing Address - Phone:847-854-5533
Mailing Address - Fax:
Practice Address - Street 1:2250 W ALGONQUIN RD
Practice Address - Street 2:SUITE 112
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156-1289
Practice Address - Country:US
Practice Address - Phone:847-854-5533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083588302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF43241Medicare UPIN
208687Medicare ID - Type UnspecifiedMEDICARE