Provider Demographics
NPI:1154305837
Name:BREITZIG, GLENN SCOTT (DC, FNP-C)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:SCOTT
Last Name:BREITZIG
Suffix:
Gender:M
Credentials:DC, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 BERRYWOOD DR STE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6515
Mailing Address - Country:US
Mailing Address - Phone:573-777-8300
Mailing Address - Fax:239-332-2145
Practice Address - Street 1:1300 E BRADFORD PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4294
Practice Address - Country:US
Practice Address - Phone:417-761-5000
Practice Address - Fax:417-761-5011
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0008078111N00000X
MO2019008101363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381-400900Medicaid
FL53991ZMedicare ID - Type UnspecifiedMEDICARE NUMBER