Provider Demographics
NPI:1386665032
Name:GLENN, KAHLIL S (MD)
Entity Type:Individual
Prefix:DR
First Name:KAHLIL
Middle Name:S
Last Name:GLENN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1626 E STATE ROAD 44
Mailing Address - Street 2:SUITE B
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-4026
Mailing Address - Country:US
Mailing Address - Phone:317-421-2012
Mailing Address - Fax:317-421-2131
Practice Address - Street 1:150 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-1236
Practice Address - Country:US
Practice Address - Phone:317-392-3211
Practice Address - Fax:317-421-2131
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01056694207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01056694OtherSTATE LICENSE
IN000000392328OtherANTHEM BCBS
INPENDINGMedicaid
INPENDINGOtherRAILROAD MCR
INPENDINGOtherRAILROAD MCR
INPENDINGMedicare ID - Type Unspecified