Provider Demographics
NPI:1679766406
Name:GLENN, BYRON CORNELIUS (MD)
Entity Type:Individual
Prefix:DR
First Name:BYRON
Middle Name:CORNELIUS
Last Name:GLENN
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1353 N MOUNT AUBURN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-1723
Mailing Address - Country:US
Mailing Address - Phone:573-332-8400
Mailing Address - Fax:573-332-8151
Practice Address - Street 1:1353 N MOUNT AUBURN RD
Practice Address - Street 2:SUITE B
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-1723
Practice Address - Country:US
Practice Address - Phone:573-332-8400
Practice Address - Fax:573-332-8151
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2016-09-01
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Provider Licenses
StateLicense IDTaxonomies
MO108285207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208155044Medicaid
MOE18759Medicare UPIN
MO208155044Medicaid