Provider Demographics
NPI:1053089318
Name:GLAZER, SAVANNAH ROSE
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:ROSE
Last Name:GLAZER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 W POTOMAC AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3149
Mailing Address - Country:US
Mailing Address - Phone:201-410-1640
Mailing Address - Fax:
Practice Address - Street 1:1675 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1110
Practice Address - Country:US
Practice Address - Phone:201-410-1640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022345363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics