MEDICARE: DR. RICHARD J GROSTERN 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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	036097434	IL
2	207W00000X	Ophthalmology Physician	036097434	IL

General Provider Information

NPI Number	:	1902881170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD J GROSTERN MD

Provider Business Mailing Address
First Line	:	1725 W HARRISON ST STE 918
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3863
Country	:	US
Telephone Number	:	312-942-2734
Fax Number	:

Provider Business Practice Location Address
First Line	:	1725 W HARRISON ST STE 918
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3863
Country	:	US
Telephone Number	:	312-942-2734
Fax Number	:	312-942-2156

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

Provider Enumeration Date	:	12/10/2005
Last Update Date	:	01/13/2013

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