1518936863 NPI number — DR. JANENE R GLYN MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518936863 NPI number — DR. JANENE R GLYN MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

GLYN

Provider First Name:

JANENE

Provider Middle Name:

R

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

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:

1518936863

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

01/23/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1285 NININGER RD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

HASTINGS

Provider Business Mailing Address State Name:

MN

Provider Business Mailing Address Postal Code:

55033-1086

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

651-480-4200

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

1285 NININGER RD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

HASTINGS

Provider Business Practice Location Address State Name:

MN

Provider Business Practice Location Address Postal Code:

55033-1086

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

651-480-4200

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

03/17/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208000000X , with the licence number:  8620A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208000000X , with the licence number: 42887 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 127968 . This is a "UCARE MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 34005200 . This is a "MEDICAID WI" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 34005200 . This is a "GROUP HEALTH EAU CLAIRE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: HP31065 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 12-00895 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 66-07835 . This is a "MEDICA URGENT CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 190150800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 27F14GL . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 370020464 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: NA9141025070 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 1072689 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".