Provider Demographics
NPI:1003873795
Name:GLYNN, THOMAS P JR (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:GLYNN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-5441
Mailing Address - Country:US
Mailing Address - Phone:765-966-2929
Mailing Address - Fax:765-966-2845
Practice Address - Street 1:1100 REID PKWY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1157
Practice Address - Country:US
Practice Address - Phone:765-983-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010288482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100319730Medicaid
IN902500Medicare ID - Type Unspecified
IN100319730Medicaid