Healthcare Provider Details

I. General information

NPI: 1497742860
Provider Name (Legal Business Name): CHARLES G GROEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8915 W GOLF RD 3RD FLOOR
NILES IL
60714-5905
US

IV. Provider business mailing address

3610 PAYSPHERE CIR
CHICAGO IL
60674-0036
US

V. Phone/Fax

Practice location:
  • Phone: 847-827-9490
  • Fax: 847-827-2241
Mailing address:
  • Phone: 847-585-7000
  • Fax: 847-240-0622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number036085244
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number01068054A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: