Provider Demographics
NPI:1497099113
Name:SCOTT D, GLAZER, M.D., S.C.
Entity Type:Organization
Organization Name:SCOTT D, GLAZER, M.D., S.C.
Other - Org Name:DERMATOLOGY ASSOCIATES OF HIGHLAND PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:CPC-D, MA
Authorized Official - Phone:847-432-4650
Mailing Address - Street 1:767 PARK AVE W
Mailing Address - Street 2:STE 310
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2400
Mailing Address - Country:US
Mailing Address - Phone:847-432-4650
Mailing Address - Fax:847-459-7929
Practice Address - Street 1:767 PARK AVE W
Practice Address - Street 2:SUITE 310
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2400
Practice Address - Country:US
Practice Address - Phone:847-432-4650
Practice Address - Fax:847-480-2616
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCOTT D. GLAZER, M.D., S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-19
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062019207N00000X
IL036059380207NS0135X
IL036073084207NS0135X
IL036102194207NS0135X
IL036111358207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI43875Medicare UPIN
ILH16889Medicare UPIN
ILC43141Medicare UPIN
ILB54301Medicare UPIN
ILC25911Medicare UPIN