Healthcare Provider Details

I. General information

NPI: 1639190200
Provider Name (Legal Business Name): GLENDON BURRESS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N. ROCKTON AVE. ROCKFORD HEALTH PHYSICIANS
ROCKFORD IL
61103
US

IV. Provider business mailing address

2300 N. ROCKTON AVE. ROCKFORD HEALTH PHYSICIANS
ROCKFORD IL
61103
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-2000
  • Fax:
Mailing address:
  • Phone: 815-971-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036087077
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number036087077
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: