Provider Demographics
NPI:1457315533
Name:GLENN, CHRIS (MD)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
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:PO BOX 140349
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99514-0349
Mailing Address - Country:US
Mailing Address - Phone:907-792-7975
Mailing Address - Fax:907-792-7901
Practice Address - Street 1:2741 DEBARR RD
Practice Address - Street 2:SUITE 401
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2961
Practice Address - Country:US
Practice Address - Phone:907-792-7975
Practice Address - Fax:907-792-7901
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG799752085R0202X
AK81222085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G799750OtherBLUE SHIELD OF CA
CA00G799750Medicaid
CA1457315533Medicaid
CACA112687Medicare PIN
WAP00605737Medicare PIN
CAG77791Medicare UPIN
CACB207629Medicare UPIN
AY977CMedicare PIN
AY977EMedicare PIN
WA8871465Medicare PIN
CA1457315533Medicaid
AY977BMedicare PIN
CACB207628Medicare PIN
CA00G799750OtherBLUE SHIELD OF CA
AY977AMedicare PIN
AY977DMedicare PIN