Healthcare Provider Details

I. General information

NPI: 1932359759
Provider Name (Legal Business Name): CAVIN GLENN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S CALIFORNIA AVE
CHICAGO IL
60608-1729
US

IV. Provider business mailing address

1500 S CALIFORNIA AVE
CHICAGO IL
60608-1729
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-6464
  • Fax:
Mailing address:
  • Phone: 773-257-6464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036124962
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: