Healthcare Provider Details

I. General information

NPI: 1396987053
Provider Name (Legal Business Name): GLENN SKOW M.D., MPH, FAAFP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2009
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W TAYLOR ST
VANDALIA IL
62471-1227
US

IV. Provider business mailing address

825 NEW YORK DR STE 2
VANDALIA IL
62471-1044
US

V. Phone/Fax

Practice location:
  • Phone: 618-283-5136
  • Fax:
Mailing address:
  • Phone: 618-283-5545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number258929
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036130323
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036130323
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: