Provider Demographics
NPI:1699703413
Name:GLASSROTH, JEFFREY (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:GLASSROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:303 E CHICAGO AVE
Mailing Address - Street 2:WARD 4-009
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4296
Mailing Address - Country:US
Mailing Address - Phone:312-503-1871
Mailing Address - Fax:312-908-5502
Practice Address - Street 1:251 E HURON ST
Practice Address - Street 2:GALTER-3-150
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-503-1871
Practice Address - Fax:312-503-1871
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
A38262Medicare UPIN