Provider Demographics
NPI:1821176124
Name:GLENN F DEVRIES
Entity Type:Organization
Organization Name:GLENN F DEVRIES
Other - Org Name:BERLIN FAMILY FOOT CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:F
Authorized Official - Last Name:DEVRIES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:920-361-3036
Mailing Address - Street 1:322 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1706
Mailing Address - Country:US
Mailing Address - Phone:920-361-3036
Mailing Address - Fax:920-361-7317
Practice Address - Street 1:322 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1706
Practice Address - Country:US
Practice Address - Phone:920-361-3036
Practice Address - Fax:920-361-7317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI467213ES0103X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0691500004Medicare NSC
WI85625Medicare PIN