MEDICARE: MITCHELL LYLE GLASER 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
1	2084P0800X	Psychiatry Physician	036053454	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598789521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL LYLE GLASER MD.

Provider Business Mailing Address
First Line	:	PO BOX 1394
Second Line	:
City	:	LA GRANGE PARK
State	:	IL
Zip	:	60526-9494
Country	:	US
Telephone Number	:	312-491-5498
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 W ADAMS ST
Second Line	:	#B
City	:	CHICAGO
State	:	IL
Zip	:	60607-2903
Country	:	US
Telephone Number	:	312-770-3512
Fax Number	:	312-770-3345

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	05/30/2024

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