Provider Demographics
NPI:1073696977
Name:GEHRKE, GLENN ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:ALLEN
Last Name:GEHRKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:67 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-5619
Mailing Address - Country:US
Mailing Address - Phone:270-554-8373
Mailing Address - Fax:270-554-8987
Practice Address - Street 1:8001 CENTERVIEW PKWY STE 215
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4276
Practice Address - Country:US
Practice Address - Phone:901-249-5905
Practice Address - Fax:901-249-5940
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080570207L00000X, 207LP2900X, 208VP0014X
MS24839208VP0000X, 208VP0014X
TN53805208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6066289OtherBLUE CROSS BLUE SHIELD
TNQ022062Medicaid
MS07274365Medicaid
P01704491OtherRAILROAD MEDICARE