Provider Demographics
NPI:1801831235
Name:VOLYN, GLEN P (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:P
Last Name:VOLYN
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 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4955
Mailing Address - Fax:208-625-4956
Practice Address - Street 1:1701 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2537
Practice Address - Country:US
Practice Address - Phone:208-625-4955
Practice Address - Fax:208-625-4956
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM13591207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0242406OtherDEPT OF LABOR AND INDUSTRIES
E65730Medicare UPIN
WAG8876569Medicare PIN
WAG8876504Medicare PIN
WA0242395OtherDEPT OF LABOR AND INDUSTRIES
WA1079128Medicaid
8855971Medicare PIN