Provider Demographics
NPI:1598782674
Name:GLENN KNOX MD PSC
Entity Type:Organization
Organization Name:GLENN KNOX MD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-292-9777
Mailing Address - Street 1:12276 SAN JOSE BLVD
Mailing Address - Street 2:#516
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8628
Mailing Address - Country:US
Mailing Address - Phone:904-292-9777
Mailing Address - Fax:904-292-1313
Practice Address - Street 1:12276 SAN JOSE BLVD
Practice Address - Street 2:#516
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8628
Practice Address - Country:US
Practice Address - Phone:904-292-9777
Practice Address - Fax:904-292-1313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75455207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDE18010OtherRAILROAD MEDICARE
FLK1480Medicare ID - Type Unspecified