Provider Demographics
NPI:1598789521
Name:GLASER, MITCHELL LYLE (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:LYLE
Last Name:GLASER
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 1:3059 N PAULINA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3000
Mailing Address - Country:US
Mailing Address - Phone:773-935-6079
Mailing Address - Fax:
Practice Address - Street 1:1101 W ADAMS ST
Practice Address - Street 2:#B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2903
Practice Address - Country:US
Practice Address - Phone:312-770-3512
Practice Address - Fax:312-770-3345
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360534542084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053454Medicaid
ILK32980Medicare ID - Type Unspecified
ILG83572Medicare UPIN