Provider Demographics
NPI:1508801697
Name:GEREMIA, GLEN (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:GEREMIA
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 1:1420 RENAISSANCE DR STE 307
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1343
Mailing Address - Country:US
Mailing Address - Phone:847-803-1000
Mailing Address - Fax:847-803-1098
Practice Address - Street 1:1420 RENAISSANCE DR STE 307
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1343
Practice Address - Country:US
Practice Address - Phone:847-803-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360624732085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E18308Medicare UPIN