Provider Demographics
NPI:1518903186
Name:ROSEBOROUGH, GLEN S (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:S
Last Name:ROSEBOROUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 LIBERTY ST NE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-8381
Mailing Address - Country:US
Mailing Address - Phone:503-371-1756
Mailing Address - Fax:503-584-7971
Practice Address - Street 1:2480 LIBERTY ST NE
Practice Address - Street 2:SUITE 110
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-8381
Practice Address - Country:US
Practice Address - Phone:503-371-1756
Practice Address - Fax:503-584-7971
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1501902086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500612667Medicaid
ORP00800072OtherRAILROAD MEDICARE
ORR150478Medicare PIN
OR500612667Medicaid
ORH25149Medicare UPIN