Provider Demographics
NPI:1184617086
Name:BABICH, GLEN S (MD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:S
Last Name:BABICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:813 STONE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-2655
Mailing Address - Country:US
Mailing Address - Phone:615-973-0026
Mailing Address - Fax:618-213-7168
Practice Address - Street 1:813 STONE CREEK LN
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-2655
Practice Address - Country:US
Practice Address - Phone:615-973-0026
Practice Address - Fax:618-213-7168
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114518208D00000X
AZ47521208D00000X
ARE-6244208D00000X
IDM-9700208D00000X
IN01077201A208D00000X
KS04-37037208D00000X
TNMD0000027058208D00000X
MOMD2002010249208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG19673Medicare UPIN