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General NPI Number Information
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NPI Number | 1356495444
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Entity Type | Individual
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Provider Name | GLEN JOSEPH HEINZL MD
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Gender | Male
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2000 PROGRESS DRIVE
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City | NEW LISBON
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State | WI
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Zip | 53950-2000
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Country | US
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Telephone | 608-562-6400
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Fax | 608-562-7382
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Provider Business Mailing Address
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Address Line | N11015 19TH AVE. P.O. BOX 499
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City | NECEDAH
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State | WI
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Zip | 54646
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Country | US
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Telephone | 608-565-7771
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 22801
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License Number State | WI
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