Provider Demographics
NPI:1063497444
Name:GLASSLEY, STEPHEN H (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:H
Last Name:GLASSLEY
Suffix:
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 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:2710 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5412
Practice Address - Country:US
Practice Address - Phone:260-373-8070
Practice Address - Fax:260-373-8071
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01018040A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000111940OtherANTHEM
00001076337 05OtherUNITED HEALTHCARE
IN1335OtherPHYSICIANS HEALTH PLAN
IN080130064OtherRAILROAD MEDICARE
4047058OtherAETNA
IN100048970Medicaid
B28060Medicare UPIN
IN070830LMedicare PIN
4047058OtherAETNA
IN070860JMedicare PIN
IN080130064OtherRAILROAD MEDICARE
IN100048970Medicaid
IN069860PMedicare PIN