Provider Demographics
NPI:1891796553
Name:BURT, GLENN B III (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:B
Last Name:BURT
Suffix:III
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 1:1901 WESTWOOD CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-2892
Mailing Address - Country:US
Mailing Address - Phone:715-355-9700
Mailing Address - Fax:
Practice Address - Street 1:1901 WESTWOOD CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-2892
Practice Address - Country:US
Practice Address - Phone:715-355-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27936207P00000X
WI27936-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34225100Medicaid
WIF35440Medicare UPIN
WI009900416Medicare ID - Type Unspecified