Provider Demographics
NPI:1851353395
Name:GROSSMAN, STEPHEN ALFRED (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ALFRED
Last Name:GROSSMAN
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 1:34659 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-1346
Mailing Address - Country:US
Mailing Address - Phone:847-676-0091
Mailing Address - Fax:847-676-2374
Practice Address - Street 1:1425 N RANDALL RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2300
Practice Address - Country:US
Practice Address - Phone:224-783-8767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360786862085N0904X, 2085R0202X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078686Medicaid
ILF55717Medicare UPIN