Healthcare Provider Details

I. General information

NPI: 1184667438
Provider Name (Legal Business Name): GLENNETTA COLEMAN MD AND ASSOCIATES, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1983 DAIMLER ROAD
ROCKFORD IL
61112-1081
US

IV. Provider business mailing address

1893 DAIMLER RD
ROCKFORD IL
61112-1081
US

V. Phone/Fax

Practice location:
  • Phone: 815-227-0055
  • Fax: 815-227-0050
Mailing address:
  • Phone: 815-227-0055
  • Fax: 815-227-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRICIA OLAGUES
Title or Position: PRACTICE MANAGER
Credential: RN
Phone: 815-227-0055