Healthcare Provider Details

I. General information

NPI: 1851353395
Provider Name (Legal Business Name): STEPHEN ALFRED GROSSMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 N RANDALL RD
ELGIN IL
60123-2300
US

IV. Provider business mailing address

34659 EAGLE WAY
CHICAGO IL
60678-1346
US

V. Phone/Fax

Practice location:
  • Phone: 224-783-8767
  • Fax:
Mailing address:
  • Phone: 847-676-0091
  • Fax: 847-676-2374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number036078686
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036078686
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number036078686
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: