Provider Demographics
NPI:1851314942
Name:THORESON, GLENN M (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:M
Last Name:THORESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:520 CHAUTAUQUA BLVD
Mailing Address - Street 2:
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072-3145
Mailing Address - Country:US
Mailing Address - Phone:701-845-6000
Mailing Address - Fax:701-845-6150
Practice Address - Street 1:520 CHAUTAUQUA BLVD
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-3145
Practice Address - Country:US
Practice Address - Phone:701-845-6000
Practice Address - Fax:701-845-6150
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND3031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12569Medicaid
MN553597200Medicaid
NDN11583Medicare PIN
D26344Medicare UPIN