Provider Demographics
NPI:1760450134
Name:WEISGERBER, GLEN A (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:A
Last Name:WEISGERBER
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 1:100 S 5TH ST
Mailing Address - Street 2:PO BOX 227
Mailing Address - City:AUBURN
Mailing Address - State:IL
Mailing Address - Zip Code:62614-1402
Mailing Address - Country:US
Mailing Address - Phone:217-438-6175
Mailing Address - Fax:217-438-6550
Practice Address - Street 1:100 S 5TH ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IL
Practice Address - Zip Code:62615-1402
Practice Address - Country:US
Practice Address - Phone:217-438-6175
Practice Address - Fax:217-438-6550
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061310Medicaid
IL14D0435318OtherCLIA
IL659970Medicare ID - Type Unspecified
IL14D0435318OtherCLIA