Provider Demographics
NPI:1578679130
Name:HYLAND, GLEN R (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:R
Last Name:HYLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 N MANDAN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3859
Mailing Address - Country:US
Mailing Address - Phone:701-751-4464
Mailing Address - Fax:701-751-4464
Practice Address - Street 1:311 N MANDAN ST STE 1
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-751-4464
Practice Address - Fax:701-751-3947
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04320032085R0001X
ND37812085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDD25372Medicare UPIN