Provider Demographics
NPI:1497701510
Name:GLOVER, CARMON L III (DO)
Entity Type:Individual
Prefix:
First Name:CARMON
Middle Name:L
Last Name:GLOVER
Suffix:III
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 8882
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-0882
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:
Practice Address - Street 1:211 S 3RD ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1915
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098224207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098224Medicaid
ILP00342997OtherRAILROAD MEDICARE
IL08232205OtherBLUE CROSS BLUE SHIELD
IL0008232056OtherBLUECROSS BLUESHIELD
IL06032182OtherBLUE CROSS BLUE SHIELD
IL08232204OtherBLUE CROSS BLUE SHIELD
ILK28186Medicare PIN
IL06032182OtherBLUE CROSS BLUE SHIELD
G83353Medicare UPIN
IL08232205OtherBLUE CROSS BLUE SHIELD