Provider Demographics
NPI:1831265016
Name:GRANDAS, NOEL (MD)
Entity type:Individual
Prefix:
First Name:NOEL
Middle Name:
Last Name:GRANDAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:HINES
Mailing Address - State:IL
Mailing Address - Zip Code:60141-3030
Mailing Address - Country:US
Mailing Address - Phone:708-202-2282
Mailing Address - Fax:708-202-2281
Practice Address - Street 1:5000 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:708-202-2282
Practice Address - Fax:708-202-2281
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113697225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113697Medicaid
IL363236791OtherTAX ID #
IL036113697Medicaid
ILI37112Medicare UPIN
IL363236791OtherTAX ID #