Provider Demographics
NPI:1902881170
Name:GROSTERN, RICHARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:GROSTERN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST STE 918
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3863
Mailing Address - Country:US
Mailing Address - Phone:312-942-2734
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 918
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3863
Practice Address - Country:US
Practice Address - Phone:312-942-2734
Practice Address - Fax:312-942-2156
Is Sole Proprietor?:No
Enumeration Date:2005-12-10
Last Update Date:2013-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097434207ZP0102X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG94101Medicare UPIN
ILL88387Medicare PIN