MEDICARE: JACK GLENN HUGULEY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SE0003X	Emergency Clinical Nurse Specialist	PA16498	CA
2	363A00000X	Physician Assistant	085003674	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	085003674	OTHER	IL	IL PA LICENSE

General Provider Information

NPI Number	:	1649244336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK GLENN HUGULEY PA

Provider Business Mailing Address
First Line	:	PO BOX 544
Second Line	:	DEPT 5390
City	:	MILWAUKEE
State	:	WI
Zip	:	53201-0544
Country	:	US
Telephone Number	:	815-713-2600
Fax Number	:	815-654-5020

Provider Business Practice Location Address
First Line	:	811 SOUTH STATE STREET
Second Line	:	SUITEB
City	:	CHICAGO
State	:	IL
Zip	:	60605-0000
Country	:	US
Telephone Number	:	312-566-9510
Fax Number	:	312-566-9511

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	02/10/2010

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Directions to “ JACK GLENN HUGULEY PA” Practice Location

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