Physician Compare National (NPI:1053356675)

HEALTHCARE PROVIDER:

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1053356675
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	3678619467
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20091008000208
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	VAN LOON
	Individual professional last name
Provider First Name	GLEN
	Individual professional first name
Provider Middle Name	R
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	OTHER
	Individual professional's medical school
Graduation Year	1965
	Individual professional's medical school graduation year
Primary Specialty	ENDOCRINOLOGY
	Primary medical specialty reported by the individual professional in the selected enrollment
Secondary Specialty 1	INTERNAL MEDICINE
	First secondary medical specialty reported by the individual professional in the selected enrollment
All Secondary Specialties	INTERNAL MEDICINE
	All four secondary specialties reported by the individual professional in the selected enrollment, separated by commas

Practice Information
Line 1 Street Address	619 OLD SYMSONIA RD C
	Group Practice or individual's line 1 address
City	BENTON
	Group Practice or individual's city
State	KY
	Group Practice or individual's state
Zip Code	420255094
	Group Practice or individual's zip code (9 digits when available)
Phone Number	2705272560
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	181327
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	MARSHALL COUNTY HOSPITAL
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	180116
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	JACKSON PURCHASE MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 2
Hospital Affiliation CCN 3	180027
	Medicare CCN of hospital where individual professional provides service 3
Hospital Affiliation LBN 3	MURRAY-CALLOWAY COUNTY HOSPITAL
	Legal business name of hospital where individual professional provides service 3
Hospital Affiliation CCN 4	180102
	Medicare CCN of hospital where individual professional provides service 4
Hospital Affiliation LBN 4	LOURDES HOSPITAL
	Legal business name of hospital where individual professional provides service 4
Hospital Affiliation CCN 5	180104
	Medicare CCN of hospital where individual professional provides service 5
Hospital Affiliation LBN 5	BAPTIST HEALTH PADUCAH
	Legal business name of hospital where individual professional provides service 5
Professional Accepts Medicare Assignment	Y

Physician Compare National (NPI:1053356675)

HEALTHCARE PROVIDER:

Individual Professional Information

Medical School Information

Practice Information

Hospital(s) Affiliation Information