Healthcare Provider Details

I. General information

NPI: 1174584866
Provider Name (Legal Business Name): GLEN R. LIESEGANG M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 HIGHWAY 268
PATTERSON NC
28661
US

IV. Provider business mailing address

PO BOX 319
PATTERSON NC
28661-0319
US

V. Phone/Fax

Practice location:
  • Phone: 828-754-6850
  • Fax: 828-758-3214
Mailing address:
  • Phone: 828-754-6850
  • Fax: 828-758-3214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31569
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: