Provider Demographics
NPI:1710193776
Name:GLENN, KELLY R (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:R
Last Name:GLENN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4227
Mailing Address - Country:US
Mailing Address - Phone:970-384-6730
Mailing Address - Fax:
Practice Address - Street 1:1906 BLAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4227
Practice Address - Country:US
Practice Address - Phone:970-384-6730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO49141207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07987846Medicaid
CO07987846Medicaid