Provider Demographics
NPI:1487654521
Name:BROOKSHIRE, GLEN H (DO)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:H
Last Name:BROOKSHIRE
Suffix:
Gender:M
Credentials:DO
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 1241
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46624-1241
Mailing Address - Country:US
Mailing Address - Phone:885-691-9888
Mailing Address - Fax:
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-523-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002322207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114315071Medicaid
IN930109846OtherRAIL ROAD MEDICARE
IN200331530Medicaid
IN000000197019OtherANTHEM
IN930109846OtherRAIL ROAD MEDICARE
G54164Medicare UPIN