Provider Demographics
NPI:1073565867
Name:GLUSMAN, MARIANA (MD)
Entity Type:Individual
Prefix:MS
First Name:MARIANA
Middle Name:
Last Name:GLUSMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4867 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3603
Mailing Address - Country:US
Mailing Address - Phone:773-561-6640
Mailing Address - Fax:
Practice Address - Street 1:4867 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640
Practice Address - Country:US
Practice Address - Phone:773-561-6640
Practice Address - Fax:773-506-4651
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-01-18
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2008-01-02
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G43681Medicare UPIN
ILL55664Medicare ID - Type Unspecified