Healthcare Provider Details

I. General information

NPI: 1013130152
Provider Name (Legal Business Name): GLEN DERRICK TRAMMELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

3248 186TH ST
HOMEWOOD IL
60430-2798
US

V. Phone/Fax

Practice location:
  • Phone: 773-869-7488
  • Fax:
Mailing address:
  • Phone: 773-869-7488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-000875
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: