Provider Demographics
NPI:1477552057
Name:GLASS, TIMOTHY ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALLEN
Last Name:GLASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11541 E WINCHESTER LN
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2040
Mailing Address - Country:US
Mailing Address - Phone:833-220-2685
Mailing Address - Fax:317-947-0839
Practice Address - Street 1:8240 NAAB RD
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-872-9580
Practice Address - Fax:317-872-6043
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01044838A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1009224OtherTRICARE
IN200073640Medicaid
IN200073640Medicaid
IN333030FMedicare PIN