Healthcare Provider Details

I. General information

NPI: 1215392576
Provider Name (Legal Business Name): LISA M GROSSMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 DEMPSTER ST SUITE 465
PARK RIDGE IL
60068-1129
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1129
US

V. Phone/Fax

Practice location:
  • Phone: 847-825-1100
  • Fax:
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SW0102X
TaxonomyWomen's Health Clinical Nurse Specialist
License Number209.013706
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209.013705
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: