Provider Demographics
NPI:1043298557
Name:SIDLER, GLEN J (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:J
Last Name:SIDLER
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 1:201 N CUMMINGS LN
Mailing Address - Street 2:P.O. BOX 310
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-2181
Mailing Address - Country:US
Mailing Address - Phone:309-444-2005
Mailing Address - Fax:309-444-2006
Practice Address - Street 1:201 N CUMMINGS LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-2181
Practice Address - Country:US
Practice Address - Phone:309-444-2005
Practice Address - Fax:309-444-2006
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060332174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1043298557OtherNPI
IL036060332Medicaid
ILD14365Medicare UPIN
IL583150Medicare ID - Type Unspecified