1629292149 NPI number — E. GLENN GLASSMAN DDS DBA ORTHOCARE SYSTEMS

Table of content: JODY CONNOLLY BSN, RN, PHN (NPI 1932926425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629292149 NPI number — E. GLENN GLASSMAN DDS DBA ORTHOCARE SYSTEMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
E. GLENN GLASSMAN DDS DBA ORTHOCARE SYSTEMS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1629292149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
709 S 5TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CHARLES
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63301-2913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-757-0770
Provider Business Mailing Address Fax Number:
636-757-0773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4005 S CLOVERLEAF DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PETERS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63376-6450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-926-3889
Provider Business Practice Location Address Fax Number:
636-926-2014
Provider Enumeration Date:
04/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GLASSMAN
Authorized Official First Name:
ELLIOT
Authorized Official Middle Name:
GLENN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
636-757-0770

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  013277 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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