Provider Demographics
NPI:1982668158
Name:GROSSMAN, BRUCE GLENN (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:GLENN
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 1:1000 GRAND CANYON PKWY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-1705
Mailing Address - Country:US
Mailing Address - Phone:847-882-5888
Mailing Address - Fax:847-882-5951
Practice Address - Street 1:1000 GRAND CANYON PKWY
Practice Address - Street 2:SUITE 301
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-1705
Practice Address - Country:US
Practice Address - Phone:847-882-5888
Practice Address - Fax:847-882-5951
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060298174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060298OtherSTATE LICENSE NUMBER
IL036060298OtherSTATE LICENSE NUMBER
D15102Medicare UPIN