Provider Demographics
NPI:1477555738
Name:DUST, GLEN E (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:E
Last Name:DUST
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 1:1000 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-2116
Mailing Address - Country:US
Mailing Address - Phone:217-762-6241
Mailing Address - Fax:217-762-1702
Practice Address - Street 1:1000 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-2116
Practice Address - Country:US
Practice Address - Phone:217-762-6241
Practice Address - Fax:217-762-1702
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068658207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360686581Medicaid
IL080027217OtherPALMETTO
IL0007000023OtherBCBS OF ILLINOIS
IL182358OtherHEALTHLINK
ILC47076Medicare UPIN
IL729391Medicare Oscar/Certification