Healthcare Provider Details

I. General information

NPI: 1396705489
Provider Name (Legal Business Name): GLEN COULOMB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S WASHINGTON ST
NAPERVILLE IL
60540-7430
US

IV. Provider business mailing address

1919 S HIGHLAND AVE STE B202
LOMBARD IL
60148-6153
US

V. Phone/Fax

Practice location:
  • Phone: 630-281-2670
  • Fax: 815-327-2475
Mailing address:
  • Phone: 630-873-7305
  • Fax: 630-416-3189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036063012
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: