MEDICARE: SCOTT EVAN GROSSBERG 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	2085R0202X	Diagnostic Radiology Physician	A95432	CA

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	:	1801831078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT EVAN GROSSBERG MD

Provider Business Mailing Address
First Line	:	250 E PEARSON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-7225
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 E PEARSON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-7225
Country	:	US
Telephone Number	:	312-540-3881
Fax Number	:

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

Provider Enumeration Date	:	06/19/2006
Last Update Date	:	08/10/2016

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