Provider Demographics
NPI:1760488191
Name:GLASSER, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:GLASSER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3 MARYLAND FARMS
Mailing Address - Street 2:SUITE 250
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5005
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:866-346-1426
Practice Address - Street 1:1325 ANDREA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-5852
Practice Address - Country:US
Practice Address - Phone:270-901-3454
Practice Address - Fax:270-901-3458
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2014-10-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY19937207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64199375Medicaid
KY080155383OtherRAILROAD MEDICARE
KY50006908OtherPASSPORT
KY000000065732OtherANTHEM
KY64199375Medicaid
KY080155383OtherRAILROAD MEDICARE