Provider Demographics
NPI:1750370102
Name:ANDERSON, GLENN B (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:B
Last Name:ANDERSON
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 1:6560 FANNIN ST
Mailing Address - Street 2:STE 944
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2761
Mailing Address - Country:US
Mailing Address - Phone:713-441-3800
Mailing Address - Fax:
Practice Address - Street 1:13300 HARGRAVE RD
Practice Address - Street 2:SUITE 390
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4373
Practice Address - Country:US
Practice Address - Phone:281-737-2932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14085R207T00000X
TXN2379207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1100323Medicaid
LAH43598Medicare UPIN
LA4A3817545Medicare PIN