Provider Demographics
NPI:1962002832
Name:COLEMAN CLINIC, INC.
Entity Type:Organization
Organization Name:COLEMAN CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENNETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-227-0055
Mailing Address - Street 1:1893 DAIMLER RD STE A
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61112-1081
Mailing Address - Country:US
Mailing Address - Phone:815-227-0055
Mailing Address - Fax:815-227-0050
Practice Address - Street 1:1893 DAIMLER RD STE A
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61112-1081
Practice Address - Country:US
Practice Address - Phone:815-227-0055
Practice Address - Fax:815-227-0050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-29
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty