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General NPI Number Information
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NPI Number | 1902881170
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Entity Type | Individual
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Provider Name | RICHARD J GROSTERN MD
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Gender | Male
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Dates
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Enumeration Date | 12/10/2005
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Last Update Date | 01/13/2013
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Provider Practice Location Address
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Address Line | 1725 W HARRISON ST STE 918
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City | CHICAGO
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State | IL
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Zip | 60612-3863
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Country | US
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Telephone | 312-942-2734
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Fax | 312-942-2156
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Provider Business Mailing Address
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Address Line | 1725 W HARRISON ST STE 918
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City | CHICAGO
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State | IL
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Zip | 60612-3863
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Country | US
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Telephone | 312-942-2734
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | 036097434
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 036097434
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License Number State | IL
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