Provider Demographics
NPI:1093763682
Name:BOYD, GLENN H (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:H
Last Name:BOYD
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 1:1203 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2530
Mailing Address - Country:US
Mailing Address - Phone:706-278-0022
Mailing Address - Fax:706-278-6360
Practice Address - Street 1:1203 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2530
Practice Address - Country:US
Practice Address - Phone:706-278-0022
Practice Address - Fax:706-278-6360
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA17510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000139202AMedicaid
GAD39456Medicare UPIN
GA$$$$$$$$$AMedicare PIN