Provider Demographics
NPI:1487758850
Name:GLASSENBERG, MYRON (MD)
Entity type:Individual
Prefix:DR
First Name:MYRON
Middle Name:
Last Name:GLASSENBERG
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 1:2740 W FOSTER AVE
Mailing Address - Street 2:LL7
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625
Mailing Address - Country:US
Mailing Address - Phone:773-878-8200
Mailing Address - Fax:773-293-4197
Practice Address - Street 1:2740 W FOSTER AVE
Practice Address - Street 2:STE 108
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3500
Practice Address - Country:US
Practice Address - Phone:773-989-5571
Practice Address - Fax:773-989-4471
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360457482084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036045748Medicaid
406120086OtherPTAN