Provider Demographics
NPI:1497757298
Name:DAVIS, GLENN ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ALAN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GLENN
Other - Middle Name:A
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1020 MCARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-2453
Mailing Address - Country:US
Mailing Address - Phone:931-728-2022
Mailing Address - Fax:931-723-1210
Practice Address - Street 1:1020 MCARTHUR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2453
Practice Address - Country:US
Practice Address - Phone:931-728-2022
Practice Address - Fax:931-723-1210
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD16760207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3017354Medicaid
A98131Medicare UPIN
TN3017354Medicare ID - Type Unspecified
TN3017354Medicaid