Provider Demographics
NPI:1881642551
Name:REYNOLDS, GLENN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:THOMAS
Last Name:REYNOLDS
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 1:200 RESEARCH DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-3049
Mailing Address - Country:US
Mailing Address - Phone:785-539-4644
Mailing Address - Fax:785-539-8010
Practice Address - Street 1:200 RESEARCH DR
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-3049
Practice Address - Country:US
Practice Address - Phone:785-539-4644
Practice Address - Fax:785-539-8010
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63930207RC0000X
IDM-11533207RC0000X
MT42180207RC0000X
KS04-40715207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP01203003OtherMCRR
E24182Medicare UPIN
ID20002859Medicare Oscar/Certification
E24182Medicare UPIN
CACA132005Medicare PIN