Provider Demographics
NPI: | 1790156032 |
---|---|
Name: | BYRON CORNELIUS GLENN |
Entity Type: | Organization |
Organization Name: | BYRON CORNELIUS GLENN |
Other - Org Name: | CAPE URGENT CARE & FAMILY MEDICINE |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | BYRON |
Authorized Official - Middle Name: | C |
Authorized Official - Last Name: | GLENN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 573-332-8400 |
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: | 63701-1727 |
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: | 63701-1727 |
Practice Address - Country: | US |
Practice Address - Phone: | 573-332-8400 |
Practice Address - Fax: | 573-332-8151 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2015-10-13 |
Last Update Date: | 2016-01-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |