Healthcare Provider Details

I. General information

NPI: 1720848609
Provider Name (Legal Business Name): BRANDON ZACHARY GLIGOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N RUTLEDGE ST
SPRINGFIELD IL
62702-4933
US

IV. Provider business mailing address

801 N RUTLEDGE ST
SPRINGFIELD IL
62702-4933
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax:
Mailing address:
  • Phone: 217-545-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: