=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154390581
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EARL G GLOECKNER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2006
-----------------------------------------------------
Last Update Date | 12/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1420 7TH ST
-----------------------------------------------------
City | MOLINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61265-2916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-762-2333
-----------------------------------------------------
Fax | 309-762-8001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1420 7TH ST
-----------------------------------------------------
City | MOLINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61265-2916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-762-2333
-----------------------------------------------------
Fax | 309-762-8001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------