1437272945 NPI number — DR. GLENN A ALLY PH.D, M.P.

Table of content: DR. GLENN A ALLY PH.D, M.P. (NPI 1437272945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437272945 NPI number — DR. GLENN A ALLY PH.D, M.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLY
Provider First Name:
GLENN
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D, M.P.
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:
1437272945
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 HOSPITAL DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70503-2852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-235-8304
Provider Business Mailing Address Fax Number:
337-235-5924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70503-2852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-235-8304
Provider Business Practice Location Address Fax Number:
337-235-5924
Provider Enumeration Date:
04/09/2007

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: 103G00000X , with the licence number:  378MP , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 378MP , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP0016X , with the licence number: 378MP , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1969559 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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