Provider Demographics
NPI:1265992614
Name:HARRIS, GLENN R (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:HARRIS
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 1:259 E ERIE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2987
Mailing Address - Country:US
Mailing Address - Phone:312-695-7950
Mailing Address - Fax:
Practice Address - Street 1:675 N SAINT CLAIR ST STE 20-100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5970
Practice Address - Country:US
Practice Address - Phone:312-695-7950
Practice Address - Fax:312-695-5747
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1638492084N0400X
IL0361638492084N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology