Healthcare Provider Details

I. General information

NPI: 1487031407
Provider Name (Legal Business Name): LUCIA GLEASON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 W FULLERTON AVE FLOOR 2
CHICAGO IL
60614
US

IV. Provider business mailing address

1000 REMINGTON BLVD STE 100
BOLINGBROOK IL
60440-4707
US

V. Phone/Fax

Practice location:
  • Phone: 773-549-7757
  • Fax: 773-549-1221
Mailing address:
  • Phone:
  • Fax: 630-914-2469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125067787
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036146576
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: