Provider Demographics
NPI:1376782870
Name:OSTROM, GREGORY L (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:OSTROM
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 SUMMIT ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-3843
Mailing Address - Country:US
Mailing Address - Phone:847-741-0372
Mailing Address - Fax:
Practice Address - Street 1:370 SUMMIT ST
Practice Address - Street 2:SUITE 5
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-3843
Practice Address - Country:US
Practice Address - Phone:847-741-0372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-07
Last Update Date:2009-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-054784207R00000X, 207RG0300X
IL36-0547842083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine