Provider Demographics
NPI:1720082555
Name:TATE, GLEN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:EDWARD
Last Name:TATE
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:LAUREL FORK
Mailing Address - State:VA
Mailing Address - Zip Code:24352-0009
Mailing Address - Country:US
Mailing Address - Phone:276-398-2292
Mailing Address - Fax:276-398-3331
Practice Address - Street 1:14558 DANVILLE PIKE
Practice Address - Street 2:
Practice Address - City:LAUREL FORK
Practice Address - State:VA
Practice Address - Zip Code:24352-3982
Practice Address - Country:US
Practice Address - Phone:276-398-2292
Practice Address - Fax:276-398-3331
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007608942Medicaid
VA007608942Medicaid
491827Medicare ID - Type UnspecifiedGROUP NUMBER
VAB05912Medicare UPIN