Provider Demographics
NPI:1063449296
Name:COLEMAN, GLENNETTA (MD)
Entity type:Individual
Prefix:DR
First Name:GLENNETTA
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GLENNA
Other - Middle Name:
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1893 DAIMLER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61112-1081
Mailing Address - Country:US
Mailing Address - Phone:815-227-0055
Mailing Address - Fax:815-227-0050
Practice Address - Street 1:1893 DAIMLER RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61112-1081
Practice Address - Country:US
Practice Address - Phone:815-227-0055
Practice Address - Fax:815-227-0050
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067471207R00000X
IL036037471207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0031603167OtherBCBS OF ILLINOIS
IL036-06741Medicaid
IL036-06741Medicaid
IL0031603167OtherBCBS OF ILLINOIS