Provider Demographics
NPI:1194985986
Name:GLENN, CHARLOTTE PEIWHA (MD)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:PEIWHA
Last Name:GLENN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 BIESTERFIELD RD
Mailing Address - Street 2:SUITE 705A
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3361
Mailing Address - Country:US
Mailing Address - Phone:847-981-6061
Mailing Address - Fax:847-981-6062
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:SUITE 705A
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:847-981-6061
Practice Address - Fax:847-981-6062
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-15
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125053552207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125053552OtherSTATE OF ILLINOIS
IL125053552OtherSTATE OF ILLINOIS
IL215188006Medicare PIN