Provider Demographics
NPI:1184667438
Name:GLENNETTA COLEMAN MD AND ASSOCIATES, LTD
Entity type:Organization
Organization Name:GLENNETTA COLEMAN MD AND ASSOCIATES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLAGUES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:815-227-0055
Mailing Address - Street 1:1893 DAIMLER RD
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 1:1983 DAIMLER ROAD
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:2006-06-14
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-06741Medicaid
IL0031603167OtherBCBS OF ILLINOIS
IL036-06741Medicaid
IL214047Medicare PIN