Provider Demographics
NPI:1023002839
Name:GUEVARRA, GLENN (RT)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:GUEVARRA
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9136A WAUKEGAN RD
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2119
Mailing Address - Country:US
Mailing Address - Phone:847-965-8890
Mailing Address - Fax:847-965-5424
Practice Address - Street 1:9136A WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2119
Practice Address - Country:US
Practice Address - Phone:847-965-8890
Practice Address - Fax:847-965-5424
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-07
Last Update Date:2007-07-09
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
IL227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364160733001Medicaid
IL364160733001Medicaid