Healthcare Provider Details

I. General information

NPI: 1902881170
Provider Name (Legal Business Name): RICHARD J GROSTERN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2005
Last Update Date: 01/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST STE 918
CHICAGO IL
60612-3863
US

IV. Provider business mailing address

1725 W HARRISON ST STE 918
CHICAGO IL
60612-3863
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-2734
  • Fax: 312-942-2156
Mailing address:
  • Phone: 312-942-2734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036097434
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036097434
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: