Provider Demographics
NPI:1659304897
Name:GLENN M LIPTON MD PC
Entity Type:Organization
Organization Name:GLENN M LIPTON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LIPTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-649-7999
Mailing Address - Street 1:989 S MAIN ST
Mailing Address - Street 2:STE. A613
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4601
Mailing Address - Country:US
Mailing Address - Phone:928-649-7999
Mailing Address - Fax:
Practice Address - Street 1:294 W STATE ROUTE 89A
Practice Address - Street 2:SUITE 110
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3754
Practice Address - Country:US
Practice Address - Phone:928-649-7999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32683208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ110515Medicare PIN