1063497444 NPI number — STEPHEN H. GLASSLEY M.D.

Table of content: STEPHEN H. GLASSLEY M.D. (NPI 1063497444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063497444 NPI number — STEPHEN H. GLASSLEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLASSLEY
Provider First Name:
STEPHEN
Provider Middle Name:
H.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063497444
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1234 E DUPONT RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825-1545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-373-9700
Provider Business Mailing Address Fax Number:
260-373-9740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2710 LAKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-5412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-373-8070
Provider Business Practice Location Address Fax Number:
260-373-8071
Provider Enumeration Date:
12/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01018040A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000111940 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 00001076337 05 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1335 . This is a "PHYSICIANS HEALTH PLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 080130064 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 4047058 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100048970 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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