Provider Demographics
NPI:1396705489
Name:COULOMB, GLEN (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:COULOMB
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 1:1919 S HIGHLAND AVE
Mailing Address - Street 2:STE B202
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6153
Mailing Address - Country:US
Mailing Address - Phone:630-873-7305
Mailing Address - Fax:630-416-3189
Practice Address - Street 1:801 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-7430
Practice Address - Country:US
Practice Address - Phone:630-281-2670
Practice Address - Fax:815-327-2475
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360630122086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02215038OtherBLUE CROSS BLUE SHIELD
ILK36122Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
IL02215038OtherBLUE CROSS BLUE SHIELD