Provider Demographics
NPI:1174584866
Name:LIESEGANG, GLEN R (M D)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:R
Last Name:LIESEGANG
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 319
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28661-0319
Mailing Address - Country:US
Mailing Address - Phone:828-754-6850
Mailing Address - Fax:828-758-3214
Practice Address - Street 1:1345 HIGHWAY 268
Practice Address - Street 2:
Practice Address - City:PATTERSON
Practice Address - State:NC
Practice Address - Zip Code:28661
Practice Address - Country:US
Practice Address - Phone:828-754-6850
Practice Address - Fax:828-758-3214
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8951919Medicaid
NC51919OtherBCBS
A98187Medicare UPIN
NC208238Medicare ID - Type Unspecified