Healthcare Provider Details

I. General information

NPI: 1073565867
Provider Name (Legal Business Name): MARIANA GLUSMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 01/02/2008

III. Provider practice location address

4867 N BROADWAY AVE
CHICAGO IL
60640
US

IV. Provider business mailing address

4867 N BROADWAY ST
CHICAGO IL
60640-3603
US

V. Phone/Fax

Practice location:
  • Phone: 773-561-6640
  • Fax: 773-506-4651
Mailing address:
  • Phone: 773-561-6640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: