Provider Demographics
NPI:1184667438
Name:GLENNETTA COLEMAN MD AND ASSOCIATES, LTD
Entity Type:Organization
Organization Name:GLENNETTA COLEMAN MD AND ASSOCIATES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-227-0055
Mailing Address - Street 1:1893 DAIMLER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61112-1081
Mailing Address - Country:US
Mailing Address - Phone:815-227-0055
Mailing Address - Fax:815-227-0050
Practice Address - Street 1:1983 DAIMLER ROAD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61112-1081
Practice Address - Country:US
Practice Address - Phone:815-227-0055
Practice Address - Fax:815-227-0050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067471174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0031603167OtherBCBS OF ILLINOIS
IL036-06741Medicaid
IL036-06741Medicaid
IL214047Medicare PIN