Provider Demographics
NPI:1497742860
Name:GROEN, CHARLES G (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:GROEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0036
Mailing Address - Country:US
Mailing Address - Phone:847-585-7000
Mailing Address - Fax:847-240-0622
Practice Address - Street 1:8915 W GOLF RD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-5905
Practice Address - Country:US
Practice Address - Phone:847-827-9490
Practice Address - Fax:847-827-2241
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360852442085R0001X
IN01068054A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000726585OtherANTHEM PROVIDER NUMBER
IL036085244Medicaid
IN201034800Medicaid
ILK03524Medicare PIN
ILF09836Medicare UPIN
IN201034800Medicaid
IL920001349Medicare PIN