Provider Demographics
NPI:1992903165
Name:BRIAN GLASS MD OB/GYN
Entity type:Organization
Organization Name:BRIAN GLASS MD OB/GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-428-3822
Mailing Address - Street 1:1109 BURLEYSON RD STE 205
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3094
Mailing Address - Country:US
Mailing Address - Phone:706-428-3822
Mailing Address - Fax:706-428-3864
Practice Address - Street 1:1109 BURLEYSON RD STE 205
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3094
Practice Address - Country:US
Practice Address - Phone:706-428-3822
Practice Address - Fax:706-428-3864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032911207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE84524Medicare UPIN