Provider Demographics
NPI:1720023930
Name:LOVELACE, GLEN S (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:S
Last Name:LOVELACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N 1ST ST STE 260
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6132
Mailing Address - Country:US
Mailing Address - Phone:208-345-3136
Mailing Address - Fax:208-345-0984
Practice Address - Street 1:333 N 1ST ST STE 260
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6132
Practice Address - Country:US
Practice Address - Phone:208-345-3136
Practice Address - Fax:208-345-0984
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6570207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010002170OtherBLUE SHIELD
ID003795800Medicaid
ID37382OtherBLUE CROSS
IDF77391Medicare UPIN
ID003795800Medicaid