Healthcare Provider Details

I. General information

NPI: 1962492900
Provider Name (Legal Business Name): GLEN N FEATHER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S MAIN ST
CANTON IL
61520-2608
US

IV. Provider business mailing address

2907 W WARDCLIFFE DR
PEORIA IL
61604-2157
US

V. Phone/Fax

Practice location:
  • Phone: 309-647-0201
  • Fax: 309-649-6880
Mailing address:
  • Phone: 309-404-1914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036079920
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036079920
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: