Provider Demographics
NPI:1275736100
Name:JOHN A. GLENN JR. CENTER FOR COMMUNITY HEALTHCARE INC.
Entity Type:Organization
Organization Name:JOHN A. GLENN JR. CENTER FOR COMMUNITY HEALTHCARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:478-374-1308
Mailing Address - Street 1:1112 PLAZA AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-9009
Mailing Address - Country:US
Mailing Address - Phone:478-374-1308
Mailing Address - Fax:478-374-0302
Practice Address - Street 1:1112 PLAZA AVE
Practice Address - Street 2:SUITE C
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-9009
Practice Address - Country:US
Practice Address - Phone:478-374-1308
Practice Address - Fax:478-374-0302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA03995207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000613874AMedicaid
GA=========OtherTAX ID
GA000613874AMedicaid
GA=========OtherTAX ID #
GA08BBXDNMedicare ID - Type UnspecifiedMEDICARE