Provider Demographics
NPI:1265429146
Name:GLASS, BRIAN A (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:GLASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
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
Practice Address - Street 2:SUITE 205
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA032911207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52255730001OtherBLUE CROSS/BLUE SHIELD
GA52255730001OtherBLUE CROSS/BLUE SHIELD