Provider Demographics
NPI:1386655116
Name:ALLEN, ROBERT GLENN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GLENN
Last Name:ALLEN
Suffix:JR
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 1:4454 W GLEN PL
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-6852
Mailing Address - Country:US
Mailing Address - Phone:605-343-1911
Mailing Address - Fax:
Practice Address - Street 1:4454 W GLEN PL
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-6852
Practice Address - Country:US
Practice Address - Phone:605-343-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2638207L00000X, 2083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Not Answered2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D25127Medicare UPIN