Provider Demographics
NPI:1760535173
Name:WIELENGA, GLENN ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ALAN
Last Name:WIELENGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:MT
Mailing Address - Zip Code:59859-1119
Mailing Address - Country:US
Mailing Address - Phone:406-826-3141
Mailing Address - Fax:406-826-5505
Practice Address - Street 1:807 S. 5TH AVE
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:MT
Practice Address - Zip Code:59859
Practice Address - Country:US
Practice Address - Phone:406-826-3141
Practice Address - Fax:406-826-5505
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT4937207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTE66828Medicare UPIN