Provider Demographics
NPI:1801814769
Name:LEVINE, GLENN LAURENCE (MD)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:LAURENCE
Last Name:LEVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:COQUILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97423
Mailing Address - Country:US
Mailing Address - Phone:541-247-3000
Mailing Address - Fax:541-247-3101
Practice Address - Street 1:790 E 5TH ST
Practice Address - Street 2:
Practice Address - City:COQUILLE
Practice Address - State:OR
Practice Address - Zip Code:97423
Practice Address - Country:US
Practice Address - Phone:541-396-3111
Practice Address - Fax:541-396-5891
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD162422208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR00000ZGBDGOtherCURRY MEDICAL PRACTICE / CURRY MEDICAL CENTER MEDICARE PART B
OR500662335Medicaid
OR93-0937095OtherCURRY HEALTH DISTRICT TAX IDN
ORR171246Medicare PIN
ORR00000ZGBDGOtherCURRY MEDICAL PRACTICE / CURRY MEDICAL CENTER MEDICARE PART B