1053364828 NPI number — GLEN P. IMLAY M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053364828 NPI number — GLEN P. IMLAY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IMLAY
Provider First Name:
GLEN
Provider Middle Name:
P.
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:
1053364828
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
90 JACKSON PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLIPOLIS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45631-1560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-886-9403
Provider Business Mailing Address Fax Number:
740-446-5153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
98 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROCTORVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45669-8163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-886-9403
Provider Business Practice Location Address Fax Number:
740-446-5153
Provider Enumeration Date:
05/19/2006

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: 208100000X , with the licence number:  20826 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: 35-08-0873 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2333906 . This is a "MOLINA MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000185246 . This is a "UNISON MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000227912 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2003261000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 310917085124 . This is a "CARESOURCE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2333906 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001714143 . This is a "MOUNTAIN STATE BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 250013535 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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