Leah Grinnage
Individual provider Active NPI Specialist · Dolton, IL
NPI 1174903124 · NPPES record last updated Jun 4, 2015
Key facts
- NPI
- 1174903124
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Specialist 174400000X
- License
- 057004251 (IL)
- Practice address
- 15317 Evers St
Dolton, IL 60419-2624 - Phone
- (708) 692-5896
- NPI assigned
- Jun 4, 2015
- Sex
- Female
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 057004251 | IL | MD | Specialist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist | 174400000X | 057004251 | IL | Yes |
Addresses
Primary practice location
15317 Evers St
Dolton, IL 60419-2624
Mailing address
15317 Evers St
Dolton, IL 60419-2624
Phone (708) 692-5896
Other providers in Dolton, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 4, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.