Provider Demographics
NPI:1114177599
Name:GLENN M. IHDE, MD, PA
Entity Type:Organization
Organization Name:GLENN M. IHDE, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:IHDE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:817-467-3000
Mailing Address - Street 1:1745 STAINBACK RD
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-3207
Mailing Address - Country:US
Mailing Address - Phone:817-467-3000
Mailing Address - Fax:817-467-3001
Practice Address - Street 1:515 W MAYFIELD RD
Practice Address - Street 2:SUITE 402
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2083
Practice Address - Country:US
Practice Address - Phone:817-467-3000
Practice Address - Fax:817-467-3001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6010174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00Z693Medicare PIN