Provider Demographics
NPI:1568499846
Name:GLOGOVAC, S VIC (MD)
Entity Type:Individual
Prefix:DR
First Name:S VIC
Middle Name:
Last Name:GLOGOVAC
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 1:12255 DE PAUL DR
Mailing Address - Street 2:SUITE 165
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2510
Mailing Address - Country:US
Mailing Address - Phone:314-291-7510
Mailing Address - Fax:314-291-0001
Practice Address - Street 1:12255 DE PAUL DR
Practice Address - Street 2:SUITE 165
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2510
Practice Address - Country:US
Practice Address - Phone:314-291-7510
Practice Address - Fax:314-291-0001
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR95132086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7672OtherBLUE CROSS BLUE SHIELD
MOA24331Medicare UPIN
MO7672OtherBLUE CROSS BLUE SHIELD