1972618056 NPI number — JEFF GLOVER MD PA

Table of content: (NPI 1972618056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972618056 NPI number — JEFF GLOVER MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFF GLOVER MD PA
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:
6
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:
1972618056
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:
PO BOX 746
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCCOMB
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39649-0746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-684-2481
Provider Business Mailing Address Fax Number:
601-684-2488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1311 ASTON AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCCOMB
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39648-2825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-684-2481
Provider Business Practice Location Address Fax Number:
601-684-2488
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GLOVER
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
HENRY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
601-684-2481

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  10993 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5023171 . This is a "AETNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00016354 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1730117 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1387509 . This is a "LOUISIANA MEDICAID" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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