Provider Demographics
NPI:1548270259
Name:GLENNON, TERRENCE (MD)
Entity type:Individual
Prefix:
First Name:TERRENCE
Middle Name:
Last Name:GLENNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 LINCOLN DR STE B
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3790
Mailing Address - Country:US
Mailing Address - Phone:618-351-4980
Mailing Address - Fax:
Practice Address - Street 1:408 LINCOLN DR STE B
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3790
Practice Address - Country:US
Practice Address - Phone:618-351-4980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-077232208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077232Medicaid
344609407-00OtherBWC OHIO
344609407-00OtherBWC OHIO
IL036077232Medicaid
E10597Medicare UPIN
ILL82528Medicare ID - Type Unspecified