Healthcare Provider Details

I. General information

NPI: 1487690285
Provider Name (Legal Business Name): LESLIE C GRAMMER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST STE 18-250
CHICAGO IL
60611-5980
US

IV. Provider business mailing address

680 N LAKE SHORE DR SUITE 1000
CHICAGO IL
60611-4546
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-8624
  • Fax:
Mailing address:
  • Phone: 312-695-9797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number036054997
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number036054997
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: