1164487864 NPI number — DR. G GLEN CHITWOOD MD

Table of content: DR. G GLEN CHITWOOD MD (NPI 1164487864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164487864 NPI number — DR. G GLEN CHITWOOD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHITWOOD
Provider First Name:
G
Provider Middle Name:
GLEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1164487864
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT 241 PO BOX 1559
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74101-1559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-243-8418
Provider Business Mailing Address Fax Number:
918-663-2281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2710 RIFE MEDICAL LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72758-1452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-338-8000
Provider Business Practice Location Address Fax Number:
501-664-0302
Provider Enumeration Date:
04/18/2006

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: 2085R0202X , with the licence number:  C5273 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: C-5273 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 118166001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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