Provider Demographics
NPI:1407857220
Name:BLUE, GLEN TROY (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:TROY
Last Name:BLUE
Suffix:
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 1:11 BLACKBERRY RD
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-8913
Mailing Address - Country:US
Mailing Address - Phone:501-268-1944
Mailing Address - Fax:501-278-3073
Practice Address - Street 1:2900 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-7323
Practice Address - Country:US
Practice Address - Phone:501-278-2868
Practice Address - Fax:501-278-3073
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-5037208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR50527Medicare ID - Type Unspecified
ARD04370Medicare UPIN