Provider Demographics
NPI:1588841308
Name:GLENN A. MCCOY, MD PLLC
Entity Type:Organization
Organization Name:GLENN A. MCCOY, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-368-3056
Mailing Address - Street 1:1700 BLUEGRASS AVENUE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215
Mailing Address - Country:US
Mailing Address - Phone:502-368-3056
Mailing Address - Fax:502-363-1627
Practice Address - Street 1:1700 BLUEGRASS AVENUE
Practice Address - Street 2:SUITE 110
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1129
Practice Address - Country:US
Practice Address - Phone:502-368-3056
Practice Address - Fax:502-363-1627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23946174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B74478Medicare UPIN
KY0668601Medicare PIN