Provider Demographics
NPI:1144246091
Name:FENTON, GLEN
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:FENTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-977-4866
Mailing Address - Fax:
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5338
Practice Address - Fax:314-268-6411
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2010-00782084N0402X
MOR5H362084N0402X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE81817Medicare UPIN
MO203006309Medicaid