Provider Demographics
NPI:1558347021
Name:RAY, GLENN W (MD)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:W
Last Name:RAY
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 1:4250 OAK KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-1409
Mailing Address - Country:US
Mailing Address - Phone:330-720-3748
Mailing Address - Fax:330-330-8284
Practice Address - Street 1:6252 MAHONING AVENUE
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515
Practice Address - Country:US
Practice Address - Phone:330-792-7418
Practice Address - Fax:330-792-9092
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV29480207P00000X
WI18356207P00000X
KY57154207P00000X
OH35.075137207Q00000X
KY57174207R00000X, 208M00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH101308100-0001OtherPENNSYLVANIA MEDICAID
OH000000038430OtherANTHEM
OH000000349348OtherANTHEM
OH2223338Medicaid
OH101308100-0002OtherPENNSYLVANIA MEDICAID
OH000000038430OtherANTHEM
OH000000349348OtherANTHEM
OHP00188500Medicare PIN
OH101308100-0001OtherPENNSYLVANIA MEDICAID
OH2223338Medicaid