Provider Demographics
NPI:1558339317
Name:SHURTZ, GLEN (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:SHURTZ
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:PO BOX 2854
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-2854
Mailing Address - Country:US
Mailing Address - Phone:316-685-3698
Mailing Address - Fax:
Practice Address - Street 1:500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-3722
Practice Address - Country:US
Practice Address - Phone:316-262-1103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-194242085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS103239OtherBCBS
515406770OtherTRICARE
KS100127010CMedicaid
P00063431OtherRAILROAD MEDICARE
515406770OtherTRICARE
KS103239OtherBCBS