Provider Demographics
NPI:1346317724
Name:BEARD, GLENN A T (M D)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:A T
Last Name:BEARD
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 S BELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4257
Mailing Address - Country:US
Mailing Address - Phone:312-674-4005
Mailing Address - Fax:312-674-4001
Practice Address - Street 1:2555 S KING DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2419
Practice Address - Country:US
Practice Address - Phone:312-674-4005
Practice Address - Fax:312-674-4001
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059554207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059554Medicaid
IL036059554Medicaid
ILE33406Medicare UPIN