Provider Demographics
NPI:1114094737
Name:BAILEY, GLEN RONALD (MPT)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:RONALD
Last Name:BAILEY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 E GENTRY WAY
Mailing Address - Street 2:STE 250
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3501
Mailing Address - Country:US
Mailing Address - Phone:208-888-0044
Mailing Address - Fax:208-888-2211
Practice Address - Street 1:3090 E GENTRY WAY
Practice Address - Street 2:STE 250
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3501
Practice Address - Country:US
Practice Address - Phone:208-888-0044
Practice Address - Fax:208-888-2211
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPT2112225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist