1457315533 NPI number — CHRIS GLENN MD

Table of content: CHRIS GLENN MD (NPI 1457315533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457315533 NPI number — CHRIS GLENN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLENN
Provider First Name:
CHRIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1457315533
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 140349
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99514-0349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-792-7975
Provider Business Mailing Address Fax Number:
907-792-7901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2741 DEBARR RD
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99508-2961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-792-7975
Provider Business Practice Location Address Fax Number:
907-792-7901
Provider Enumeration Date:
04/14/2006

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:  G79975 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 8122 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X , with the licence number: 8122 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00G799750 . This is a "BLUE SHIELD OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G799750 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1457315533 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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