1134218779 NPI number — GLENN STEPHEN WHEELESS M.D.

Table of content: LUKE GREGORY HUFFAKER DNP, NP-C (NPI 1619471331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134218779 NPI number — GLENN STEPHEN WHEELESS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHEELESS
Provider First Name:
GLENN
Provider Middle Name:
STEPHEN
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:
1134218779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4780 N JOSEY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARROLLTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75010-4615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-492-1334
Provider Business Mailing Address Fax Number:
972-492-5174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4780 N JOSEY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75010-4615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-492-1334
Provider Business Practice Location Address Fax Number:
972-492-5174
Provider Enumeration Date:
10/12/2006

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: 207X00000X , with the licence number:  G0280 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XX0005X , with the licence number: G0280 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 6484850003 . This is a "MEDICARE NSC - EFFECT 02/01/2011" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8B7873 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8CR163 . This is a "BCBS TX 02/01/2011" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00935338 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TXB126769 . This is a "MEDICARE PART B - EFFECT. 4-20-11" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 123405606 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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