Provider Demographics
NPI:1407021348
Name:GLENN M KOTEEN M.D., LLC
Entity Type:Organization
Organization Name:GLENN M KOTEEN M.D., LLC
Other - Org Name:GASTROENTEROLOGY OF CENTRAL OREGON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOTEEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-728-0535
Mailing Address - Street 1:2450 NE MARY ROSE PL
Mailing Address - Street 2:STE 210
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7132
Mailing Address - Country:US
Mailing Address - Phone:541-728-0535
Mailing Address - Fax:541-647-5125
Practice Address - Street 1:2450 NE MARY ROSE PL
Practice Address - Street 2:STE 210
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7132
Practice Address - Country:US
Practice Address - Phone:541-728-0535
Practice Address - Fax:541-647-5125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25338261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR120175OtherMEDICARE #
OR022737Medicaid
OR120175OtherMEDICARE #