Healthcare Provider Details

I. General information

NPI: 1467450098
Provider Name (Legal Business Name): GLEN K. LOCHMUELLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 DEAN ST SUITE L
ST CHARLES IL
60175-1066
US

IV. Provider business mailing address

2210 DEAN ST SUITE L
ST CHARLES IL
60175-1066
US

V. Phone/Fax

Practice location:
  • Phone: 630-377-5000
  • Fax: 630-377-5028
Mailing address:
  • Phone: 630-377-5000
  • Fax: 630-377-5028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number036078381
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036.078381
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: