Provider Demographics
NPI:1164667069
Name:DR ROSSER LTD
Entity Type:Organization
Organization Name:DR ROSSER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSSER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-736-1555
Mailing Address - Street 1:4403 W LAWRENCE AVE
Mailing Address - Street 2:SUITE : 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2513
Mailing Address - Country:US
Mailing Address - Phone:773-736-1555
Mailing Address - Fax:773-736-1552
Practice Address - Street 1:6362 N WINTHROP AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660
Practice Address - Country:US
Practice Address - Phone:773-338-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-05
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042751Medicaid
IL036042751Medicaid