Provider Demographics
NPI:1972590537
Name:GLOVER, MARK W (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:GLOVER
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:2115 S FREMONT AVE
Practice Address - Street 2:SUITE 3000
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2239
Practice Address - Country:US
Practice Address - Phone:417-820-7708
Practice Address - Fax:417-820-7951
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO01548103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO680007342OtherRR MEDICARE
AR183800719Medicaid
MO493583108Medicaid
MO1972590537Medicaid
OK200286220AMedicaid
P00251264OtherRR MEDICARE
ARP00894315OtherRR MEDICARE
MO493583124Medicaid
P00251264OtherRR MEDICARE
ARP00894315OtherRR MEDICARE
704440115Medicare ID - Type Unspecified
R00903Medicare UPIN
OK200286220AMedicaid
MO493583108Medicaid