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NPI Code Detail

MEDICARE: CHARLES G GROEN MD

MEDICARE: CHARLES G GROEN MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12085R0001XRadiation Oncology Physician036085244IL
22085R0001XRadiation Oncology Physician01068054AIN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1000000726585OTHERINANTHEM PROVIDER NUMBER
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1497742860
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHARLES G GROEN MD
Provider Business Mailing Address
First Line : 3610 PAYSPHERE CIR
Second Line :
City : CHICAGO
State : IL
Zip : 60674-0036
Country : US
Telephone Number : 847-585-7000
Fax Number : 847-240-0622
Provider Business Practice Location Address
First Line : 8915 W GOLF RD
Second Line : 3RD FLOOR
City : NILES
State : IL
Zip : 60714-5905
Country : US
Telephone Number : 847-827-9490
Fax Number : 847-827-2241
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/30/2005
Last Update Date : 11/04/2011

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Directions to “ CHARLES G GROEN MD” Practice Location

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