Provider Demographics
NPI:1578676565
Name:GEORGER, GLEN (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:GEORGER
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 1:12810 N BELLFLOWER CT
Mailing Address - Street 2:
Mailing Address - City:PLATTE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64079-7808
Mailing Address - Country:US
Mailing Address - Phone:816-510-0702
Mailing Address - Fax:
Practice Address - Street 1:904 WOLLARD BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MO
Practice Address - Zip Code:64085-2229
Practice Address - Country:US
Practice Address - Phone:816-470-5432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108171207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100344120BMedicaid
25663033OtherBCBS
930079462OtherRAILROAD MEDICARE
KS100344120DMedicaid
KS100344120AMedicaid
KS100344120CMedicaid
MO208516211Medicaid