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General NPI Number Information
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NPI Number | 1619304342
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Entity Type | Organization
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Legal Business Name | GLUECK MD, LLC
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Dates
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Enumeration Date | 09/26/2013
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Last Update Date | 01/27/2014
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Provider Practice Location Address
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Address Line | 600 CENTRAL AVE SUITE 315
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City | HIGHLAND PARK
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State | IL
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Zip | 60035-3211
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Country | US
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Telephone | 847-786-0048
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Fax |
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Provider Business Mailing Address
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Address Line | 600 CENTRAL AVE SUITE 315
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City | HIGHLAND PARK
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State | IL
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Zip | 60035-3211
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Country | US
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Telephone | 847-786-0048
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JENNIFER SHANA GLUECK
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Credential | M.D.
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Telephone | 917-903-7047
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 036133880
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License Number State | IL
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