Provider Demographics
NPI:1558434001
Name:PADILLA, GLENN B (X-RAY TECH)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:B
Last Name:PADILLA
Suffix:
Gender:M
Credentials:X-RAY TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 LEGACY DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-5194
Mailing Address - Country:US
Mailing Address - Phone:815-577-8200
Mailing Address - Fax:815-577-8300
Practice Address - Street 1:11600 LEGACY DR
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-5194
Practice Address - Country:US
Practice Address - Phone:815-577-8200
Practice Address - Fax:815-577-8300
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211705Medicare PIN