| Organization Name: | PHYSICAL MEDICINE CLINIC OF GRANITE CITY LTD |
| NPI Number: | 1083986541 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | BUD CHOMBIRUN (MEDICAL DIRECTOR) |
| Mailing Address: | 2861 Madison Ave Granite City |
| State: | IL US |
| Postal Code: | 620403614 |
| Phone Number: | 6188774000 |
| Fax Number: | |
| NPI Enumeration Date: | 01/31/2012 |
| NPI Last Update Date: | 01/31/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332900000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Non-Pharmacy Dispensing Site |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A site other than a pharmacy that dispenses medicinal preparations under the supervision of a physician to patients for self-administration. (e.g. physician offices, ER, Urgent Care Centers, Rural Health Facilities, etc.) |