Healthcare Provider Details

I. General information

NPI: 1356495444
Provider Name (Legal Business Name): GLEN JOSEPH HEINZL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 PROGRESS DRIVE
NEW LISBON WI
53950-2000
US

IV. Provider business mailing address

N11015 19TH AVE. P.O. BOX 499
NECEDAH WI
54646
US

V. Phone/Fax

Practice location:
  • Phone: 608-562-6400
  • Fax: 608-562-7382
Mailing address:
  • Phone: 608-565-7771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22801
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: