Provider Demographics
NPI:1942318795
Name:MANDEVILLE, GLENN A (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:MANDEVILLE
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 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-242-3110
Mailing Address - Fax:812-242-3795
Practice Address - Street 1:1429 N 6TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1037
Practice Address - Country:US
Practice Address - Phone:812-242-3110
Practice Address - Fax:812-242-3795
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041222A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
020024441OtherRAILROAD MCARE PALAMETTO
IN100337060Medicaid
INP00834915OtherRAILROAD MEDICARE
000000089623OtherANTHEM
020024441OtherRAILROAD MCARE PALAMETTO
000000089623OtherANTHEM
IN859910UMedicare PIN
IN265130A3Medicare PIN