Healthcare Provider Details

I. General information

NPI: 1619009875
Provider Name (Legal Business Name): MICHAEL BARRY GROVER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 LINCOLNWOOD DR
EVANSTON IL
60201-2049
US

IV. Provider business mailing address

2340 LINCOLNWOOD DR
EVANSTON IL
60201-2049
US

V. Phone/Fax

Practice location:
  • Phone: 847-869-4912
  • Fax: 847-869-2848
Mailing address:
  • Phone: 847-869-4912
  • Fax: 847-869-2848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number36-068860
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036068860
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: