Healthcare Provider Details

I. General information

NPI: 1609307305
Provider Name (Legal Business Name): RYAN JEFFREY GLUTH D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

319 NW 42ND WAY
DEERFIELD BEACH FL
33442-8088
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 954-673-7926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036150444
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: