Provider Demographics
NPI:1003922147
Name:GLENN, MARTHA E (MD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:E
Last Name:GLENN
Suffix:
Gender:F
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:PO BOX 1000
Mailing Address - Street 2:DEPT 34 WOMENS DIAGNOSTIC GROUP PLLC
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120
Mailing Address - Country:US
Mailing Address - Phone:901-383-8860
Mailing Address - Fax:901-383-8985
Practice Address - Street 1:6215 HUMPHREYS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120
Practice Address - Country:US
Practice Address - Phone:901-227-9650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN308612085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN300138547OtherMEDICARE RR
TN4053347OtherBCBS
AR98185OtherBCBS
TN3838028Medicaid
MS05720002Medicaid
AR149402001Medicaid
MS05720002Medicaid
TN3838028Medicaid