Provider Demographics
NPI:1366462475
Name:JONES, GLYN E (MD)
Entity Type:Individual
Prefix:MR
First Name:GLYN
Middle Name:E
Last Name:JONES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1001 MAIN STREET
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-2037
Mailing Address - Country:US
Mailing Address - Phone:309-495-0200
Mailing Address - Fax:309-676-6545
Practice Address - Street 1:1001 MAIN STREET
Practice Address - Street 2:3RD FLOOR
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-2037
Practice Address - Country:US
Practice Address - Phone:309-495-0200
Practice Address - Fax:309-676-6545
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036118115208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
7215166OtherBCBS OF ILLINOIS
IL036118115-1Medicaid
ILK37419OtherMEDICARE ID TYPE UNSPECI
ILK37419OtherMEDICARE ID TYPE UNSPECI