Provider Demographics
NPI:1639190200
Name:BURRESS, GLENDON
Entity Type:Individual
Prefix:
First Name:GLENDON
Middle Name:
Last Name:BURRESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 N. ROCKTON AVE.
Mailing Address - Street 2:ROCKFORD HEALTH PHYSICIANS
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103
Mailing Address - Country:US
Mailing Address - Phone:815-971-2000
Mailing Address - Fax:
Practice Address - Street 1:2300 N. ROCKTON AVE.
Practice Address - Street 2:ROCKFORD HEALTH PHYSICIANS
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087077208000000X, 2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087077Medicaid
ILL84378Medicare PIN
ILG36127Medicare UPIN