Provider Demographics
NPI:1952462681
Name:ALBERTSON, GLEN R JR (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:R
Last Name:ALBERTSON
Suffix:JR
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 1:1120 MONTANA ST
Mailing Address - Street 2:PO BOX 481
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-1858
Mailing Address - Country:US
Mailing Address - Phone:208-934-4433
Mailing Address - Fax:208-934-8643
Practice Address - Street 1:1120 MONTANA ST
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-1858
Practice Address - Country:US
Practice Address - Phone:208-934-4433
Practice Address - Fax:208-934-8643
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID282NC0060X282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDE69401Medicare UPIN