Provider Demographics
NPI:1124337605
Name:GLEN A WEISGERBER MD SC
Entity type:Organization
Organization Name:GLEN A WEISGERBER MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISGERBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-438-6175
Mailing Address - Street 1:100 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IL
Mailing Address - Zip Code:62615-1402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 S 5TH ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IL
Practice Address - Zip Code:62615-1402
Practice Address - Country:US
Practice Address - Phone:217-438-6175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL659970Medicare PIN
IL036061310Medicare PIN
ILC45224Medicare UPIN